HomeMy WebLinkAboutApp-Permit-Compliance Unit #1��� .16 70Fss..... .. �
No.. ...
THE COMMONWEALTH OF MASSACHUSETTS
BOARD OF HEALTH
.
........... OF ........ Y.Aq m..0 0-7- ......................................
Appliratiou for 11ispooal Work.5 Tonotrnrtinn 1hrmit
Application is hereby made for a Permit to Construct (.)e) or Repair ( ) an Individual Sewage Disposal
System at
....... '?._ "1 i. T..(...----.-C..►1-,r�.�..Z................ ................ W...=--�'--...T---- '---- cy). e 4AP.--------
i L9cation - ddressor Loo N
14 Cl�.
i:-r.� .. Crt�.f2_YC�,
Owner a—
/F `� i� i:.2} X a
Installer Address 1 J�
U
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Type of Building Size feet
feet
U
Dwelling —No. of Bedrooms ......... ................................Expans>on Attic ( ) Garbage Grinder
Other — T e of Building No. of persons------_•_ -----________._- Showers — Cafeteria
Otherfixtures ------_---_-- ----------------------------- ------------------•------------•--------
WDesign Flow________________�_-i__ ---.-....___._gallons ps u n per day. Total daily flow __......_.__..._..vr.2, .... gallons.
WSeptic Tank — Liquid capacity -f -A a -gallons Length.$_ =_(J- "__ Width.'+.'-.1.P"Diameter ________-__-_ Depth.5._-..+,,
Disposal Trench — No. _-__-----_-------- Width .................... Total Length ---------- ......... Total leaching area ......... _----------sq. ft.
o (
Seepage Pit No_____________ ...... Diameter -__-_L.
.__..... Depth below inlet_....__....._.... Total leaching area ... ;W-7 ... sq. ft.
Z Other Distribution box ( -I'--Dosing tank ( )
~4 Percolation Test Results Performed b _.1..__VP�L::J....._.. Date .... --. -1-- "____$. _.
,_l Test Pit No. I... :minutes per inch Depth of Test Pit ..... Depth to ground water-. -----
(i Test Pit No. 2................minutes per inch Depth of Test Pit .................... Depth to ground water ........................
P4-------------------------------------------------------------------------------------•--•----------- ----.....---...------------------•-•.......-------•--••--
0 Description of Soil ---Q i .. ...... -�S�_ �v�) � *� V i� S d l t""_
---------•----------------------------------------
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 TIT1L 5 of the State Sanitary Code — The undersigned further agrees not to place the system in
operation until a Certificate of Compliance has been su b he oar a
Zu
Signed. -- l ........
- _..._
Application Approved BY ------- - ----- --- = - - ._ i
Date
Application Disapproved for the f owing reasons------------------------------------•------------------•------•----------------------
Date
Permit No �'-y`.0227---------------------•---. Issued ....... - ....................
Date
THE COMMONWEALTH OF MASSACHUSETTS
_ BOARD OF HEALTH
................. _OF....
✓FYI ...........................................................
Trrtifirabr of T.omplitnrr
THIS I T CERTIFY, at the I dividual wa Disposal System constructeii (L -)or Repaired ( )
--
by........... ......... ...=-------- Y i_ .5.._.. !�' -
/''� Installer
at- - ' �� ` "--=� ...... - �... �-.. C---------------------------------------------------------------------•-•-....... ------------_----
has been installed in accordance with the provisions of TITTEE 5 of The State Sanitary Code as described in the
application for Disposal Works Construction Permit No;'- ---- ................... dated___;_:____„-____
THE ISSUANCE OF THIS CERTIFICATE SMALL NOT BE CONSTRUE® AS A GUARANTEE THAT THE
SYSTEM WILL FUNCTION SATISFACTORY.
DATE....................... _ ..-------- Inspecto...........................