HomeMy WebLinkAboutApp-Permit-Compliancer? YAK1VUU !.H H. iU i U -1 -Fl.
Town OfifI�e ui� 'i ?
No. ..?. s South, Yarn;put;l, N -A Q.Z3,65rt ZS .....
THE COMMONWEALTH OF MASSACHUSETTS
BOARD OF HEALTH
............t..D.. cR 1 ............OF........ ------------------------------------------
Appliration for Disposal Murks Tonstrurtion f rrmff
Application is hereby made for a Permit to Construct (( ) or Repair ( ) an Individual Sewage Disposal
�jSystem at:g 0:2
�C
............ ......
l7�
^Location - Address or Lot No.
1.1.Ul7J.. Owner ..... . .... . . ...... ....... ........ .........-.-...............
Address ----• - ..............................
\\ : \ Y..syfeu........ ..................................^----..............•----------------------------------...........
Installer Address Gy `
Type of Building Size Lot ... -_./ .......... .....®
...Sq. feet
U Dwelling —No. of Bedrooms .............................. . . -Expansion Attic ( ) Garbage Grinder ( )
Other — TYPe of Building ............................ No, of persons...._....__.._....._._.._... Showers Cafeteria
( )
Other fixtures --•---•-•---------------------------------------•--•
WWDesign Flow..............7`�.. ........................gallons per person per day. Total daily flow....... . .........................gallons.
W
Septic Tank — Li uid' ca acit t gallons Len ---- -`.-.-. Width ... -.6......- Diameter ................ Depth -.4
..........
x Disposal Trench — No ..................... Width .................... Total Length .................... Total leaching area .................... sq. ft.
Seepage Pit No ------- ?' ........... Diameter-_. Depth below inlet.. .__Q °.__. Total leaching area..1!?! . ,sq -€t-. 4& P Pw
Z Other Distribution box (DQ Dosing tank ( ,)
1..q 4, Test Results Performed by.LQf..._ ... .9`1 .......... Date--- .................................
ato
s Test Pit No. I .... 5�. n.minutes per inch Depth of Test Pit ... l . `�.. Depth to ground waterl.4.4.............
Test Pit, No. 2 ----------------minutes per inch Depth of Test Pit .................... Depth to ground water ........................
p�......-••••---------•----•-•--------------•-•-------•-•--••--------•-•....--•-••......•-•-----•-----.........................................................
ODescription of Soil ................... �---------------------------------------•--------------••-•-------•--------------------------•-----••......----•---•...
W
.------------------------------------------------------------------------------------------- W --•-•-----•- ----------•-----.....-•--------------••-•-•-----------------------•--•--------•--------------•------------•-----------•--••...------.............-------•---••-----•---•---------•-
UNature 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 TITLE 5 of the State Sanitary Code — The undersigned further agrees not to place the system in
operation until a Certificate of Compjlce has been i hued by the board of hea h.
J' `Jigned j= -fig. --•----- • --- ---- --------------------------- `.I `..v... -
� ate
Apli n Approved By..: ----........ ...................................... ..._.. �....--- ate..----------
Date
Application Disapproved for the following reasons-----------------••------•---------•------•--------••-----...------...----...----------...-•••----•----••-...._�
---------------•---......----•--•----.........---------...........----......-----•--...----•-----......•-.--•-----...•--••----•-----=-•-••-•-----..._._...--•--•••-------••-----------•----....----------
Date
Permit No U.....-- -Z ----------------------_.... Issued. --.-.7- ��- �. g.. ...............................
Date
THE COMMONWEALTH OF' MASSACHUSETTS
BOARD OF HEALTH
....... .................... OF.."/ ..... ......................................................
(grr if iratr of faomplittorr
THI I TO CERTIFY, That the Individual Sewage Disposal System constructed ( or Repaired
( )
by-- 1N �1..:.. .._-----------------------. ......................................................................................._
� �„- Installer
at -----i t?�••-- t X.fn�-�.= 5� -= ....--CV t---.- -- : -_.•--•---------------------------------------• ---•-- • •--------------.--.--•-
has been installed in accordance with the provisions. of TITLE 5 of The State Sanitary Code as, described in the
application for Disposal Works Construction Permit No._.�5,_. ............... ated_.71. -3I r?.. .........:-----------
THE ISSUANCE OF THIS CERTIFICATE SHALL NOT BE CONST".77AS A GUARANTEE THAT THE
SYSTEMA Wit FUNCTION SATISFACTORY.
L i s
DATE....... � ` r _.. --_S..!i^/ +- ... Inspecto � I - .......... -- ---- ------------------------------