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HomeMy WebLinkAboutApp-Permit-Compliancea U a a W W x Z w 0 w U Y i Fmcl. ........... THE COMMONWEALTH OF MASSACHUSETTS BOAR® OF HEALTH WR' ...............OF.......... w!!... ................................................ Appliratiou for Disposal Works Toustrurttun Fermi# Application is hereby made for a Permit to Construct * or Repair ( )Q an Individual Sewage Disposal System at: LftSj.F ............................... �/� N �C Location - Address �A ----------------------------------------- Owner Owner --- --'- "-.--`'E= v ��_ --- Installer ...•' or Lo� ............................................. __ .. Lyl�b _)?!1 ✓ ......................................... Address Address Type of Building�J Size Lot.... � O, ��O-------Sq. feet Dwelling — No. of Bedrooms .__......_ 4............................Expansion Attic ( ) Garbage Grinder ( }� Other —Type of Building ............................ No. of persons ............................ Showers ( ) — Cafeteria ( ) Other fixtures .................................. Design Flow .......... t1 ------- ------------------gallons per �er day. Total daily flow ............................................ gallons. Septic Tank — Liquid' capacity.i .gallons `Length_W.-O'i_.. Width..6'`-0 1.. Diameter ................ Depth.41_10!.. Disposal Trench — No. ...... I............. Width ... . 1j .............. Total Length .... 7.fa_____._._ Total leaching area___1U0_0 ----- ft. Seepage Pit No ..................... Diameter .................... Depth below inlet .................. .. Total leaching area .................. sq. ft. Other Distribution box (/) Dosing tank ( ) Percolation Test Results Performed by ------ LjO94D.... US5. ... .`. �+1=-_..�N r-.......... Date ........ 7=11.A.0-------------- Test Pit No. 1.. L- -.....minutes per inch Depth of Test Pit ----- fo.o........ Depth to ground water ----- �->rvim--....... Test Pit No. 2 ... LZ..minutes per inch Depth of Test Pit......_2.Z..... Depth to ground water ....tej%l----____ t 4 �1�� -- z- ................... `....�..--------------------------•..........-- -- . . Description of Soil-------------- (;2=18 --- h2 .�?fh�Y. S ?------------------------.4,.-2 . ... M = Sf1 t2--------------------------- ----...---•--------•---------------••-•.._.18-.---3Q.... 3 ....._!ra------------------x-16...--E--oow..5i� .......-------- Q- ® - _ <SE n =---------------------0 .... ---- 5 Nature of Repairs or Alterations — Answer when applicable .................. -_-__ --- h-: -00 ..... .......... Agreement: The undersigned agrees to install the aforedescribed Individual Sewage Disposal System in accordance with the provisions of ii TE 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 e bo d of health. Si ed ------------ 2 Date . Application Approved By. - :�� ` �Q - `- Date Application Disapproved for the following reasons-....................................................... --------------•----------------------------•------- .I-------------------------------•------------------------ --------------------------•---•-------•-------------•--------------------------------•-•--------•-------------------------.._._...------------•----••- •--------- ----••------------•-------•---•---- Q ..-------Date ------ Permit 1Vo. 41 I57 ----------------------- Issued-_- --- Permit �Z Date / THE COMMONWEALTH OF MASSACHUSETTS BOARD OF HEALTH .................: `.................... OF .........`...............`.......................................................... (Irr#ifirat a of Toutpli anrr THIS IS TO CERTIFY, T Individual Se ge Disposal System constructed ( ) or Repaired WIr Installer ll��.��at•---•------•-... .f-�tc,I-.-4j=�`- has � been installed in accordance with the provisions of TIe State Sanitary C e as de• in the application for Disposal Works Construction Permit No....0....._.._... dated___.. "_.. T ............. THE ISSUANCE OF THIS CERTIFICATE SHALL NOT BE CONSTRUED AS A4UARANTEE THAT THE SYSTEM L F�CTIOrTISFACTORY. 6 DA-------�--------------------------------- Inspector----- 'azzf . •----•------.. .-1- ----------•-----------'--•------- ---------- -•