HomeMy WebLinkAboutApp-Permit-ComplianceY��l� a
i'vUa6d
a5'�}
Town 'O °fHlr' Buil i;i
No...�? ...�5 South Yarrnouln, ,ti �c.vj,4 FHS..: . ._....._
THE COMMONWEALTH OF MASSACHUSETTS
BOARD OF HEALTH
16.60-0 ............. oF............ :.% d .............................................
Applirtt#ion for Disposal Works Tous#rurtiun "amit
Application is hereby made for a Permit to Construct (,X) or Repair ( ) an Individual Sewage Disposal
System at:
....�'4 ... o►� ............................................... ............. .....__....L ...-d ..............................................
X.Le_ddore s ---. or t No�y�
Owi ... Address
W Waki Z ... .......... ..............................---•--..........._.............:...
Installer Address
Type of Building Size Lot ..... ✓.�.,.Q_.`f .... Sq. feet
U Dwelling — No. of Bedrooms .......... .....Expansion Attic ( ) Garbage Grinder ( )
'4 Other — T e of Building No. of persons ............................ Showers Cafeteria
Other fixtures ..............................................
w Design Flow ............ .......................gallons per person per day. Total daily flow ............. s %30 ...........•....... gallons.
WSeptic Tank —Liquid capacity.Z -gallons Length..... & ....... Width________ ______ Diameter................ De,Pth_ _. _..I.......
x Disposal Trench — No. ..... %............. Width ..... ID........... Total Length ......s�� g 7zi� -sgrft cr-f'�.
Total leaching area ....... .... ....
Z Seepage
Pit No. box ( ) Diameter._. Dosing tank Depth
th below inlet ................... Total leaching area .................. sq. ft.
'-' Percolation Test Results Performed by.......... . 4�Q .. ZL � �./iUC _----. Date....... - 2..-.........
a
,...1 Test Test Pit No. I...X.2----minutes per inch Depth of Test Pit....�s�2......... Depth to ground water....-/.��-�....:..
Test Pit.No. 2................minutesper inch Depth of Test Pit .................... Depth to ground water........................
P4'
O°
x
v
w
x
V
----------------•----------.........-•--.-•--
Description of Soil---------�-............
----------------------- ---------------•----------------------------------------------------------------------------------------------------------------..........---------
Nature 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 TITIN:, 5 of the State Sanitary Code — The undersigned further agrees not to place the system in `
operation until a Certificate of Compliance has bee issued by the board of h th.
Signed: _ =................... . ----- ........-- •----...
c D t
Application Approved BY ....Lli.41-----..... .....---•-----•.....--------- ��1.-------------
Date
Application Disapproved for the following reasons:.............................................................................................................._
���� Date
Permit No....55.-. 1 s 2' -- __ Issued ...... ¢1.1. .........................
Date
THE COMMONWEALTH OF MASSACHUSETTS
•t
BOARD OF HEALTH
.......................................... OF .............................. .....
( trufirab of f1 omplittnrr
THIS IS TO CERTIFY, That the Individual Sewage Disposal System constructed ( or Repaired ( )
by--------�-�---- - ------- ---------•---•--•------•-------------.. :_...- -----.....:.....m...... _..:... ..........-----•- ---._.........----------
Installer
at....... .. -----........ ........:........ ...... ----. ------------- ------
has been installed in accord nce with the provisions of TITLE 5 of The State Sanitary Codg as de crlbed in the
application for Disposal Works Construction Permit No...___� ..... gid -- --........4... dated ...... _{ ..7� �' ..............
THE ISSUANCE OF THIS CERTIFICATE SHALL NOT BE CONSTRUED AS A GUARANTEE THAT THE
pyo SYSTEM WILL FUNCTION SATISFACTORY
DATE.......................................................... Inspector......'1..iC� -