HomeMy WebLinkAboutApp-Permit-ComplianceNo.._.�1__4� F.C.
THE COMMONWEALTH OF MASSACHUSETTS
BOARDOFHEALTH
T.. OF 0��
.............. . ...............................................
Appliratinn for Disposal Warks Tonstrnr#ion Prrmit
Application is hereby made for a Permit to Construct (x) or Repair ( ) an Individual Sewage Disposal
System at:
................. P_...ST �^ '....................-------•-------------- ........ .... 60i 6 O A:--•...•-�---••--•-------..............--
ZtDS Location - Address or Lot No.
.......... —-------------•-•-••----------------............................... .......----.--------.•-----------------------...............--------•-----------------------------
�^ C) ner Address
--------------------------- J � --•-------. ....................................................
Instalier Address
Type of Building Size Lot.. ---------Sq. feet
Dwelling—No. of Bedrooms------------9'............................Expansion Attic ( ) Garbage Grinder ( }
Other — Type of Building ............................ No. of persons ............................ Showers ( ) — Cafeteria ( )
Other fixtures .......................................................
Design Flow ............. • ......................gallons per person per
Septic Tank —Liquid capacity. =---gallons Length-5..-
Disposal
ength8.._Disposal Trench — No...... i ............. Width ----- K9............ Tot
Seepage Pit No ..................... Diameter .................... Depth
Other Distribution box ( k Dosing tank
Percolation Test Results Performed by.._.___�D. .._.SE
y. Total daily w ---------- `-��--------•--•-•----------pllons.
...... Width i!AQ ..... iameter................ Depth S_.-'4-"
Length____.2S ------ T tal leaching area -_3 �__..____..sq. ft.
ow inlet .................... otal leaching area .................. sq. ft.
Test Pit No. 1..L Z-_ ...... minutes per inch Depth Test
it Test Pit No. 2___�Z..__.-minutes per inch -th o Test
* Frco0" t...o r 5-�jssa
-------------------••-------------- - ------
Description of Soil -.........................
- r 5........................ ----- ---
4R — q(, t -t . S Aran w Z" N
--------------------------------------------- -144---- M --
Nature of Repairs or Alterations;— Ans3
.............. Date-- . �-12-.-n---------------
Depth to ground water ...... l............
Depth to ground water..... 153-----------
�Z O - 48 T 5 ! T%w-
--- — ...... -----..............
4-- -`tb S !�...
2 - si.
1�.. M = S �---------
Agreement: ✓
The undersigned agr s to install the a redescribed Individual Sewage Disposal System in accordance with
the provisions of ii - — r tae State Sanita y Code — The undersigned further agrees not to place the system in
operation until a Certificate o Compliance has ee issue t rd of health.
_--___---.......�--�40----------------------------- ---
Application
t ned.+j
�-- ---` Dat �..
Approved By = Dat
Application Disapproved for the following reasons--------------------------•--•-----------•------------•-•-----...------------------. ••-------•-----------•-•----
.--------------------------•-•---------------------------------------------.....------•------------•...------ ...........
c . / to
�-j
Permit No ----- _vq-�.l�------------------------ Issued- -i •----•-!�-•�-•�"l----t----
Date
THE COMMONWEALTH OF MASSACHUSETTS
BOARD OF HEALT
............0 Gj.......OF..................5 ! M......... ...........
...........................
Tertifiratr at Toutpltttnrr
TH- I TO CE TIF That the In',*vidual Sewage Disposal System constructed ( or Repaired ( )
by... ... Q �-------- .. r---------��-------------------------------------------------------------------------•------------------------....------------.
at.-_hi..l1 -.qK.✓�,: Ci_ _!_..........................
taller -----------------------------------------------------------
has been installed i accordance with the provisions of iii-`— j o - The State Sanitary Code as described in -the
application for Disposal Works Construction Permit No.___ � '_� ��7 ____._... dated ---------
THE ISSUANCE OF THIS CERTIFICATE SHALL NOT BE CONSTRUED AS A GUARANTEE THAT YHE
SYSTEM WILL FUNCTION SATISFACTORY.
DATE........................•--••----------.............._--------------•----------- Inspector