HomeMy WebLinkAboutApp-Permit-ComplianceNo.�!5- Z-Z—
THE COMMONWEALTH OF MASSACHUSETTS
BOARD OF HEALTH fl
Fim �............
Appliraatinn for Utgpa i al Works Tnnitrnrtiun Famit
Application is hereby made for a Permit to Construct ( ✓) or Repair ( } an Individual Sewage Disposal
V System at
L!ItmE� Lo
Location - Address or. Lot No.
- R ---------------------------••------•---_. 9 �--- (?I _YV --- —L - �t1._. 2. !i,�? 1.T.! .....
w, 1S ( oil,9 &4,erss Ce H, VV1I(�
_ _______ ............... .. r....._.........._...._....._._._._..._._.._..... ....................... ._..._.__......__....___.__ ........__.._......__ _
a Installer Address
Type of Building Size Lot_JQ0`.ZQ®...... Sq. fet
U Dwelling —No. of Bedrooms ....... 3.................................Expansion Attic ( ) Garbage Grinder (V-,*')'
Other — Type of Building No. of persons__•-________•-__•_-------___ Showers — Cafeteria
P-1 Other fixtures------------------------------------------------------------•••---•-•-•-------•......--------•-•-•----
Design Flow____________ ........................gallons per person..p_r day. Total dailyyflow.._. �----------------------------------
1:4
gal
_1'ons.W _------•_-•-----.-_--.--..
Septic Tank — Li uid ca acct 15 gallons Len th_)�_��Width_FZ__ Diameter ................ Depth ---V�1Z
EFF
x Disposal Trench — No. _-_..-••_--_----_•._ Width•..• ................ Total Length_____...-........... Total leaching area .................... so. ft.
Seepage Pit No ----_-------------- Diameter ------- l.�_.___ Depth below inlet .... 5�........... Total leaching area�5S4. 3-'_•.s/ft.4ID
Z Other Distribution box ( ) Dosing tank ) qp
'–' Percolation Test Results Performed by--R..-.F _ �J % N- u�_ _._....._ Date.-�_tl.�'�__-
V----------- ----
,4 Test Pit No. 1 --- : :._._minutes per inch Depth of Test Pit ---- ,�_6_o� ____ Depth to ground water_% ONZ..__.
Test Pit No. 2................minutes per inch Depth of Test Pit .................... Depth to ground water ........................
-� �� -• } 7i --•- -------•-----------------------------------------------------------
6
-----------------------•-------.----- -------------•---
Description of Soil --Q-: LCA (�'�. (, _ �-...... �_•
-- _ M_------- _5A1Qr %------------------------------
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 iiTLE 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 the board of health.
Signed.�c �l–.iGJAG!�
Da e
Application Approved BY--95JC__44440(ell ------------------------------•----------------------•-- ------ 1__155...............
Date
Application Disapproved for the following reasons------------------•------------------------------------•------•--------------------------------------------•----
--------------------•------------------------------------------------------------------------------------•--------•---••----•---•---•-•-----•---------•--.-----•••-••-•••-----•••--------••------------
2
_2 1 j Zj l0S
Permit No ........:........._......_-----------------------_._.. Issued - -- ----- ------ -- Date ------
Date
THE COMMONWEALTH OF MASSACHUSETTS
BOARD OF HEALTH
.......................................... OF .....................................................................................
%'Urdifirtttr laf TomptiFatta
THIS IS TO CERTIFY, That the Individual Sewage Disposal System constructed ( ) or Repaired ( )
by----------------------------------------------------- ----------------------------------•-----------------------------=•............................................................................
Installer
at----------------•-----------------------------•---------------_-_-------•----------------------------- -----------------------------------------------------------------------------------------------
has been installed in accordance with the provisions of i �" 'r. 5 of The State Sanitary Code as described in the
application for Disposal Works Construction Permit N o.-_---:--._•--.. __ .................... dated__---` -�-!.-'.:1 =------.--.--•---------
THE ISSUANCE OF THIS CERTIFICATE SHALL NOT BE CONSTRUED AS A GUARANTEE THAT THE
SYSTEM WILL FUNCTION SATISFACTORY.
DATE................................................................................ BS---------------------------------•--......--------_.. Inspector....-•----••--•-•--••-.................................................