HomeMy WebLinkAboutApp-Permit-Compliancef N................
5.........
THE COMMONWEALTH OF MASSACHUSETTS
BOARD OF HEALTH
OW.A ....--.....OF..........i�i4. .� 0VTkt....
Appliration for Uh4vntial Works Tonotrurtinn pamit
Application is hereby made for a Permit to Construct (/,) or Repair ( ) an Individual Sewage Disposal
System at:
--..._.... !.._...._ u ds o d-� 3 .......... p - - 2.0
y�ocation - Address or Lot No. y�
fi. L `.. 'LG tri ----� .....1% f ../.. ~.!T.
c�ri o r.----... '1"!ca-ct.� iL41----- V S o. @.z �►. r s
....-----•••.--...._...............••-------•------•----
Owner Address
a Installer Address
d Type of Building Size Lot ... M. aa:R__......Sq. feet
UDwel ing —No. of Bedrooms ------ ..................................Expansion Attic ( ) Garbage Grinder ( )
p_l Ot r —Type of Building ............................ No. of persons ............................ Showers ( ) — Cafeteria ( )
a Other fixtures ............................
W Design Flow......._:, . ......................gallons per person per day. Total daily flow .........._.._.._ 2—.7-0.. ___.___._._..gallons.
R4 Septic Tanl% i�cluid capacitykA9.9gallons Length ...... $....... Width __..._._`Y.... Diameter ................ Depth ---- `t.......
Disposal �' No..... i .............. Width.... Z.9.......... Total Length..... >-ti`....._. Total leaching area ..... .e._6 ..... sq. ft., 26u 6 F
Seepage
Pit Pit
box ( ) Dosing tank Diameter.._ � th below inlet .................... Total leaching area ........ :......... sq. ft.
z Other
�-+ Date. 31 ° ! 8�
Percolation Test Results .Performed by.._....._.��. ---- ------------------�
�a Test Pit No. I ...... Z- .... minutes per inch Depth of Test Pit ...... 0........... Depth to ground water-__ - ............
Test Pit No. 2................minutes per inch Depth of Test Pit ------ 7.......... Depth to ground water ---- .........
•--•------------------•----------...._... --....----•--•---•---------------
Description of Soil• -•-.._,,._Se ....ins..... Vr^---...._
O�- �'----------
x
W- --------------------------------------------------------------------------------------------------------------------------------•----------------------------•------------•----------.
UNature of Repairs or Alterations — Answer when applicable............................._..........__.____...........__.................__.__....._......_.
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Agreement:
The undersigned agrees to install the aforedescribed Individual Se e Disposal System in accordance with
the provisions of TITY-L 5 of the State Sanitary Code — The under ign urther agrees not to place the system in
operation until a Certificate of Compliance has ben ssued by t rd iealth.
gned- - --- _- — ------------------------------------------------------ 1 ate Date 1....
Dn
Application Approved By -1.40,2 ... ........ ��2��r :.
Date
Application Disapproved for the following reasons- --------------•-.- -_--- ------ .---•--------------------------....---- •---------------•-.
-------------------••-•-------------•---------------------------•....------------•---------------••---•-----•-• --------•---------•-----•-----------------------------------------------------.......---
Date
PermitNo --------------------------------------------------------- Issued --------------------------------------------------------
Date
THE COMMONWEALTH OF MASSACHUSETTS
BOARD OF HEALTH
�- >�--n.OF.............
/..F� i.............................................................................
...................
(9rdifirat ( out ltttnrr
THIS IS TO CARTIFY, That the Individual Sewage Disposal System constru ed ( ) or Repaired ( )
bY..............••--...........--... Q...&)J.c K -r -'z- = ._4. cll¢—..--_60..---- �
/n/� Installer
at................ �� ......41106-010------ --`l-•-------- -----------_ �=--- ---- .................................................................7----•----
has been installed in accordance with the provisions of TITLE 5 oiThe State Sanitary Code as described in the
application for Disposal Works Construction Permit No..__.__ :!----------- dated ......... ..............................
THE ISSUANCE OF THIS CERTIFICATE SHALL NOT E - TRUED AS A GUARANTEE T T THE
SYSTEM WILL FUNCTION SATISFACTORY.
DATE .............. ����................................. Inspector..... . c�----------