HomeMy WebLinkAboutApp-Permit-ComplianceNo.. 1 Fms ..............
VC. .
LTH
THEBOARD AOF OFMASSACHUSETTSTs
....... .OF ....Y ..?-.I+J ®.Q -f
Appliration for Uiiposal Works Tonstrurtion jJamit
Application is hereby made for a Permit to Construct (X) or Repair ( ) an Individual Sewage Disposal
System at:
.............4.97- %E/r Cglo � "V 1T& �S a 19040 �O crTt+ Y,gYemo
.............•--......--------..................-------••--•----------------...-----•......----•---•-----• --- ..-• -------......... _
ocation - Add ss or Lot N
o, ... �! �' .... -.. 3 x _../. ......................................... s'.." � s' 8
Owner Address
------•-•-•-•-••-_.... e-ze-5•................................................•-----•-•--•------••----••.----- -•-••-••--•...
Installer Address
Type of Building Size Lot.' Z...�zal...._Sq. feet
Dwelling —No. of Bedrooms............................................Expansion Attic ( ) Garbage Grinder ( )
Other — Type of Building ............................ No. of persons ............................ Showers ( ) — Cafeteria ( )
Otherfixtures . •. • --------•-•-•------------------------------.-•--•-------------------------------------------•----------------•-----------------------------
Design Flow ............. --------- .� __gallons per person pFr day. Total djilyOflow ......_......_....__...-a�_3_- ------gallon;
Septic Ta LW Liquid capaclty1�_----.gallons I ength_ __` �?____ Width__ __.i....___ Diameter ................ D�e.Ptl '_._'_4'_..
Disposal Ta
h — No. __.1 ............... Width ... h$.......... Total Length ..... Total leaching area ... d7_.z �-=_.sq. ft.
Seepage Pit No -----------------_- Diameter.................... Depth below inlet .................... Total leaching area .................. sq. ft.
Other Distribution box Dosing nk
Percolation Test Results Performed by..... '�r �I� RIV .............. Date --_t_7
Test Pit No. 1WX_..�rinutes per inch Depth of Test Pit..__al....... Depth to ground water ..... 4-1............
Test Pit No. 24-011.. Z-aiinutes per inch Depth of Test Pit._..`24. ...... Depth to ground water .... 6P ............
----------------•--••----- •------------ ---•---•--••-------- ••.----•-----------....__.....-------•--•------•----_...
N /ns I9itlh A%�0 A �� �/va
Description of Soil ------02- 4FA------•--.FY---- ` - 'zg -.-------•-••----------------------------
CN
Ca.00-1.0.0 .....----•-------------------------------------
------------------------------------------------------------------------------------------------------------------------------------------------------------------------•-•---•---------•---•-----------
Nature of Repairs or Alterations — Answer when applicable................................................................................................
-•--------------------------•------••----------------------•------------•---•-------------•-----.....---.....-----------------------...----------------•----------------------...-------•-----•----•••--
Agreement :
The undersigned agrees to install the aforedescribed Individual Sewage Disposal System in accordance with
therovisions of TITi.;...
p of the State Sanitary Code —The undersi ned further agrees not to place the system in
operation until a Certificate of Compliance has been i y o d of health.
�> D e
Application Approved •-•-----•--------- mo''`t —----------
Date
Application Disapprove or the following reasons-------------•----•----------•----•--•------------------------•--------------------------------------------------
--••--•-•-•---•----------------------------------------------------------------------------•--------•------------------------.....-------------------- -----------------------------------•-------------
Date
PermitNo ......................................................... Issued ....---------------------------...---• --••-----.••---
Date
THE COMMONWEALTH OF MASSACHUSETTS
BOARD OF HEALTH
.......................................... OF .....................................................................................
Trrtifiratr of T-amphatta
THISjS,.,TO CER TI L', That the Individual Sewage Disposal System constructed (_�) or Repaired ( )
�_
by.... 7 f.l+1
e;
at.................... ZL.;.-------• }................. -------_- �C. -........ . c...... r
has been installed in accordance with the provisions of TITLE j of The State Sanitary Code escr bed in the
application for Disposal Works Construction Permit No .... 0.t.".--_�------ dated ----- z ._ .... =r ............
THE ISSUANCE OF THIS CERTIFICATE SHALL NOT BE TRUE® AS G RANT THE
SYSTEM WILLFU CTION S TISFACTORY. c
DATE-------��P--��--'- ---........................... Inspector..-- - ----== --- -- --- - -- -- --
..........