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HomeMy WebLinkAboutApp-Permit-ComplianceNo.D...z THE COMMONWEALTH OF MASSACHUSETTS BOARD OF HEALTH T.Q..tn)............... OF ...... (jt.AkW%'0Q.-J-L--------------......-----_-------------------------- Appl ration for Disposal Works Tonstrur#ion Prrmi# Application is hereby made for a Permit to Construct System at: ............ w:_..ya.......... Loca "on • Address -. . Ow er Installer Type of Building ) or Repair ( V/ an Individual Sewage Disposal ......................•---•----------•---•---•-•-•---•---••--•---.................-----------•--•- or Lot o. ..-!aVACA 4he.V ---�--------••wz...y ................. Address ..f &acLk'__..jeA------- ---- -----------•--- Address Size Lot ............................ Sq. feet Dwelling —No. of Bedrooms ......... T.v1l?.......................Expansion Attic ( ) Garbage Grinder ( ) Other — Type of Building ............................ No. of persons ............................ Showers ( ) — Cafeteria ( ) Otherfixtures ...--•..................................................................•-------------- Design Flow............................................gallons per person per day. Total daily flow ............................................ gallons. Septic Tank —Liquid* capacity ............ gallons Length ................ Width ................ Diameter ................ Depth ................ Disposal Trench — No ..................... Width .................... Total Length .................... Total leaching area ................... sq. ft. Seepage Pit No ..................... Diameter .................... Depth below inlet .................... Total leaching area .................. sq. ft. Other Distribution box ( ) Dosing tank ( ) Percolation Test Results Performed by.......................................................................... Date ........................................ Test Pit No. I................minutes per inch Depth of Test Pit .................... Depth to ground water ........................ Test Pit No. 2................minutes per inch Depth of Test Pit .................... Depth to ground water ........................ Descriptionof Soil ........................................................................................................................................................................ .._....---•--......•--••--••--•------...-•--•----.......•-•-•-•-------•--••--•..............•-...---•-....--•----------•---•••--•---•-------------•-------..._ ........... ....... ------•----•-- UNature of Repairs/ or Alterations — Answer when applicable.........-,l.a cr�,_,,,�Ag1____, LEAs �,,,,fD�7- 4�16k........... ' ------.R- t ... ST L ............................................................................................................................... Agreement: The undersigned agrees to install the aforedescribed Individual Sewage Disposal System in accordance with the provisions of TIT1Z 5 of the State Sanitary Code — The undersigned further agrees not to place the system in operation until a Certificate of Compliance has been issued by the board of h"Ithh. Sign ----- * ---...... -- . S .. Q..._._.. at ApplicationApproved By ... - -• -•-----....--•.......-•--•---•................•-----....-----......_..._..__... Date Application Disapproved for the f old ing easons---------------•-----....------------.._...------------•-------....-•--•---------•---------........--•........ _. ..............•-----..__......._..--•-----•-----•-•----------•-•-••--------------------------•--•----•---••----------•-------......._------•-----•---•-•--------...._..........._...-.--•--------... Date Permit No............ ------------------ - Issued.. ......... THE COMMONWEALTH OF MASSACHUSETTS BOARD OF HEALTH o..VJ:.A) .............. 0F ...... '.A.A.,VA. asi.+_-4.................. Tertifiratr of Tompliam THIS IS TO CERTIFY, Th4t the Ind; Disposal S7stem constructed ) or Repaired ( X by--- -------------•••--••-----•------•-------••- E -----•----- -----------••------•---____________-_______________-___-_____---__-_---______-_____---____ Installer {................... ..................--•-•�•-----. C{_}./. t- ,U. t4.e i � � - (AL�.��.....�.,+!4�Q-kali /3�.i� �i-...._..... has been installed in accordance with the provisions of TIT F 5 of The State Sanitary Code as described in the application for Disposal Works Construction Permit No ....... �,_.._.__._. dated.........�.."-57n'---Q-_._...... THE ISSUANCE OF THIS CERTIFICATE SHALL NOT BE CONSTRUED AS A GUARANTEE THAT THE SYSTEM WILL FUNCTION SATISFACTORY. DATE....' ......................... ...... �......... 4.`.::........... Inspector.`:-_._. ......--•- -• -- ..... __....... .....-........._........ f'