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HomeMy WebLinkAboutApp-Permit-Compliance) I ;ACHUSETTS No.•--.X _�...! D.®.`" Fms...."tr 5 ................ THE COMMONWEALTH OF ,MAS �wi1 i BOAR® OF HEALTH Q�p rf . - .O F ..... ..� ------------------------------...................... L.I ppliration for UisVoiial Works Tomtrnrtion 1krmit Application is hereby made for a Permit to Construct ('--)'or Repair ( ) an Individual Sewage Disposal System at ...... 'I ...�........ ... ............f ...------------er ......._._.._........ Location - Address• V or4g 7Lot Address : .......... ...•••--- a r%CLAt. C7_r " ..C- ------------------------------------ Installer Address Type of Building SizeLot__.'�'�• ....Sq. feet Dwelling —No. of Bedrooms .......................................Expansion Attic ( ) Garbage Grinder ( ) PL4Other — T e of Building _.... No. of persons ............................ Showers — Cafeteria Other fixtures ............................... . . W Design Flow ............... .................... gallons per person per day. Total da �� flow .............. 2- Z -_-..-____..--..._gal f WSeptic Tank — Liquid capacity/.. ;.q_gallons Length._R_K'­ Width.'.lf......_._ Diameter ................ Depth_ ..�5__._....__. x Disposal Trench — No . .................... Width .................... Total Length .................... Total leaching area ....................sq. ft. Seepage Pit No --------- 1�..____---- Diameter..... Z©_.______. Depth below inlet --- �_.�.�_..__. Total leaching area.. �_f'y..�..'-_.,sq. ft. Z Other Distribution box ( ) Dosing tank ( ) '-' Percolation Test Results Performed by..7_�'`74�� .._. .. _._� ..._.._ Date_ ..__ _ f9 s Test Pit No. 1 A__Zta..minutes per inch Depth of Test Pit..._..___ Depth to ground water.. . .......... Test Pit No. 2K_4?_minutesper inch Depth of Test Pit____Depth to ground water________________ --------------------------------------------•----------------------------------------------- ------------------------------ Desc'ription of Soil----rmo''--- Wo6Z. r,Ar7..... -0 X44' s—3r........................................... 9� ``---i-t--s-................................... � r4vz4"-� .5 G=s ... v✓.rz/ ��•� -5 -------------------------------------••--------------•----------•-_.. --------------------------------------------------- - Nature of Repairs or Alterations — Answer when applicable _______________________________________________________________________________________________ ------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------- Agreement : The undersigned agrees to install the aforedescribed Individual Sewage Disposal System in accordance with the provisions of 'LITTLE y g g P Y 5 of the State Sanitary Code —The undersigned further agrees not to lace the system in operation until a Certificate of Compliance has be�e1,I issu by the bo rd of health. Signed - C` fl --------- -- - -------- --- -.. �, % < Date Application Approved B -•--•--•--•--•----------------------- - --a)z.----- -- -- =t'---- - --------.... ----- or the following re¢ f- _N- - U ----- � ............................................. -------•--•-------------------•----•-------------------------------------- -----------------. ---•-----------•---------•--- Date PI - Permit No. - -- J�ja--------------------- Issued . � ..�� "•-_ ate THE COMMONWEALTH OF MASSACHUSETTS BOARD OF HEALTH 7vw.c�........ oF......... Z -red. ' ................................... WIrrtifirab of TI -I ptiattrr THIS IS TO CERTIFY, T ndividual Sewage Dis osal S- stem constructed or Repaired ( ) i --------------------------------------------- �... _40Zq&._ � -- -1 _ T_ ...� \ Installer -Py----------------•--------------•---------------•------- i----- Uf.&S.-f--- 5��------------------------------------------------------------------- has been installed in accordance with the provisions of TITLE j of The State Sanitary Cod . �e ed in the application for Disposal Works Construction Permit No-.___-__-J7_''-��a2--------- dated-__.__�r --- -----•................. THE ISSUANCE OF THIS CERTIFICATE SHALL NOT BE CONSTRUE® AS A GUARAN EE THAT THE SYSTEM WILL FUNCTION SATISFACTORY. DATE---------------------------------------------------------------------------------- Inspector