HomeMy WebLinkAboutApp-Permit-ComplianceNo.h,............
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THE COMMONWEALTH OF MASSACHUSETTS
BOARD OF HEALTH
®. tJ.......O F ........................................ ..............................
Appliratinn for Disposal Iforks Tonstrudiun thrmit
Application is hereby made for a Permit to Construct) or Repair ( ) an Individual Sewage Disposal
System at: f �- -E7 '-
L.
.. {� ocatio Add (tl�.�.. ._...... .... -•-. o. Lot__No................................«.......
Owner•_.•-'._-_.•••-•-__-. Address
. • E1�':T_.QUI ......MP
.............................................
........._.............••-•---••----------------•-....................
Installer Address
Type of Building Size Lot j_2b0 )..... q. feet
Dwelling —No. of Bedrooms............................................Expansion Attic ( ) Garbage Grinder ( )
Other — Type of Building ............................ No. of persons ............................ Showers ( ) — Cafeteria ( )
Otherfixtures .................................... �--------•--•------•----------------•-----•-•---•-•----- .............
Design Flow ............. 1.1-10.......r.,� gallons per �r �ay. Total dafy � ow......... �- 3----- ---.---.---•-.--. lon
Septic Tank —Liquid capacity "WOO"
Length..tom .6 .... Width:.. �__�._ Diameter :............... Depth...��LD--
Disposal Trench — No ..................... Width •................. Total Length ...........
Total leaching area......----__ .......sq. ft.
Seepage Pit No ........ t........... Diameter ....... 1�....._ Depth below inlet...... e......... Total leaching area----.. ... _ .t ..1q. ft.
Other Distribution boxy) Dosing tank ( )
Percolation Test Result' Performed by ..... t .. fti1rv� �..................... Date .....Lr?... 8 6
Test Pit No. 1--- �-'7 :.minutes per inch Depth of Test Pit .... J� :...... Depth to ground water .... (1ao-bo.'��......
Test Pit No. 2 ..... A=I minutes per inch Depth of Test Pit .... t4........ Depth to ground water .... MP6 � ....
Description of Soil B .
.. i
................................... .-AT ...... Mpt.
-----•-•-•--•------•--------•-------------------•---•----•-----•-•------------•........
Nature of Repairs or Alterations — Answer when
tr----------------tt----•-•-- • -...............
_. l �c/L e^i�d.�O�c ,t..r.
'....................
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Agreement:
The undersigned agrees to install .the afored cr' ed In
the provisions of LITLZ 5 of the State Sanitary C e — The
operation until a Certificate of Compliance has been is ed b t
Application Approved
Application Disapproved for the f oll=ing
---------------------•--......-......•--......../.....-------------•----......................
.� �...�Y
Permit No --------------------------------
F1O7jl A)" THE COM
Seyva Disposal System in accordance with
d furt . r agrees not to place the system in
............................................................................ ........
q Dau
Issue.d.. .-_----. • -
Date