HomeMy WebLinkAboutApp-Permit-ComplianceNo -9 :`,3*7
THE COMMONWEALTH OF MASSACHUSETTS
BOARD OF HEALTH
-rO.4Sl.K................OF.....YA�Pr�1
, ppliration for Disposal Iforks (9nukrurtion Fermi#
Application is hereby made for a Permit to Construct or Repair ( ) an Individual Sewage Disposal
System at
..L o 4.91 ................................................. C ��'T' !'.-AG.�t..._.. P.._?�D...........
Location - Address or Lot No.
....... X15.4 �b1x�.�'...IA&...•-------•----•................. �Q X...«73 1,0 g '1....�F."�l!Y!s,, ��� ......_..
.... ... ..
Owner / Address
t r ►..... e
................................................... 4r..w.. .1 ........................ = ._.._.,;....,.... ......
Installer Address
Type of Building 3Size Lot ._!S-6 S Sq. feet
Dwelling — No. of Bedrooms............................................Expansion Attic ( ) Garbage Grinder ( )
Other — Type of Building ............................ No. of persons ............................ Showers ( ) — Cafeteria ( )
Otherfixtures.--•-••---------•........................................••........•---
....................
•------•••••-•.....
Design Flow........................X ........... gallons per person per day. Total daily flow ....................... 17.3 9....... gallons.
Septic Tank —,p Liquid' capacity).0_�..gallons LengthA':-1..".. Width' ` R `!. Diameter ................ Depth �'..�'�..
Disposal 4c�-n- P No 2.._.._..._.. Width.... 1.1 ........... Total Length .... 1_7.......... Total leaching area._Z Fl.._......sq. ft.
Seepage Pit No ..................... Diameter .................... Depth below inlet .................... Total leaching area ....... .......... sq. ft.
Other Distribution box ( ) Dosing tank ( ) Js/e3
Percolation Test Results Performed by....S.WI�.&MAP&C....................................... Date l P
Test Pit No. 1.4E94A minutes per inch Depth of Test Pit .... !2.0 ... _._. Depth to ground water SG..
Test Pit No. 2................minutes per inch Depth of Test Pit .................... Depth to ground water .......................
-------------------------------------•---------------.---------•--•---- ....
._...--------------..-.- •....------.............-------------
*.............
Description of Soil......__.A7
ME
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-------------------------5.... S'_tl/G.---•--------•--------------.......-•----.....-------•--.....----
-----------------------------------------------------------------------------------------•-•-----•--•-----...-••---------------......•--------•-....-------•----•------•-•----••-....--•-•----•--....
Nature of Repairs or Alterations — Answer when applicable...............................................................................................
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Agreement
The undersigned agrees to install the aforedescribed Individual Sewage Disposal System in accordance with
the provisions of T ITLE, 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 y the board of health
Si ned_
,....... .............
/bate
Application Approved BY ...... ..........
........... Dain .......
D
Application Disapproved for the f ollounng reasons: ................... ..................................................... ... ..,.._
--•-------------------------•--•-•••-•--•---••-•-•--_.......... •----••--•••-•--••--•......••. . ................ •---•... _ .._. i..
Dt
Permit No ..... J9,X...... 31".7_. ----------------_ Issued ............. c r...& %2 ... ..:.,
Date
THE COMMONWEALTH OF MASSACHUSETTS
BOARD OF HEALTH
........................ I................. OF ................... ...............................................................
Trrfifirate of (Dont littnrr
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 TIT�`j 5 of The State Sanitary Code s escribed in the
application for Disposal Works Construction Permit No ....... _ .]--q .................. dated___._______ _f..__.__..............
�..i
THE -ISSUANCE OF THIS CERTIFICATE SHALL NOT BE CONSTRUED AS A GUARANTEE THAT THE
SYSTEM Wl&hVNCTION SATISFACTORY.
DATE------jjjffgjW•-••••••••--•---••••-•-•--••---•-----•----•--•-•-•---- Inspector ....................................................................................