HomeMy WebLinkAboutApp-Permit-Compliance - Unit 1- No...
THE COMMONWEALTH OF MASSACHUSETTS
BOARD OF HEALTH
---'-'---...OF ......
Appliratiou for Uhivaaal 10ork.6 Tomitrurtion Vantic
Application is hereby made for a Permit to Construct (N) or Repair an Individual Sewage Disposal
System at:
la . ................ L-07, 0_3 ..........
7.1-ee ------------ 7 -------------------- - _49P —C1( 0 * ---- ----
Aderess 'I jr Lot No.
L --I L)
.gcation
-.- Z��;:-- ---- --- --------------
Owneii.
I --------- ----- M ------ --- ....
Her Address
Installer
I �7C6
Type of Building Size Lot. ,a
&0_1_Sq. feet
Dwelling — No. of Bedrooms ------------- 21 ---------------_ --------- Expansion Attic Garbage Grinder
POther—Type of Building ............................ No. of persons ............................ Showers Cafeteria
4
P�q Other fixtures ------------_---------- ................. i. ....................................................... ..................................
W
'M�&per day. Total daily flow ------------_------- .......... gal
Design Flow ................. 1_1_0 ................. gallons pe Ions.
P4 Septic Tank—Liquid capacityIP-OP..gallons Length ... b -'..k." Width.'+':4q,__ Diameter ------------- Depth -.5-''..T'
Disposal Trench — No- ------------_----- Width .................... Total Length .................... Total leaching area .................... sq. ft.
Seepage Pit No -_--____I...______... Piameter ------ ---- Depth below inlet ........... Total leaching area-__ - i�.OJ _..sq. ft.
Other Distribution box ( Dosing tank ( )
i )- . ... Date...
Percolation Test Results Performed by.._)R_1j, .... 0..'j4JEA&A -_ -------- - C----_ -i -
Test Pit No. I ... i inutes per inch Depth of Test Depth to ground water._7__________________._
Test Pit No. 2 ................minutes per inch Depth of Test Pit______-._-_--_______ Depth to ground water._...........__.........
---------------------------------- * ........ * --------------•-----------------------•----
--- * --------------------- *"* -------------- ----------------------------------------•------•---------
----------------------"----------------*----------------
0 Description of Soil.o.",_ — ......1-----• - ..................................................
L.S.-
.......... ( .........................................
-a..... iZT.Y .......�:A.l --- ::p .......................................................................................................................
U Nature of Repairs or Alterations — Answer when applicable ------ .......................................................................... ..............
................................................................................................................................................................................. ......................
Agreement:
The undersigned agrees to install the aforedes,cribed Individual Sewage Disposal System in accordance with
the provisions of T I T 12 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.
Sign
ApplicationApproved By_ a - --------- - . .. .. . ........... ................................... .................... Dat - e --------------
...................................................................................
Application Disapproved for the following reasons: .............................
.............................. .......................................................................... I ...... --------- ...........................................................Date ....................
.... ..............
Permit No_ Issued ...
............................................. Date
THE COMMONWEALTH OF MASSACHUSETTS
BOARD OF HEALTH
ff
............. ... OA�`.'.:An ... OF .... ...................................
Turdifiratr of Tomptiatta
THIS IS Ta_CERT1FY,.T1jat thpd.vidual4SeNyagp DispoASystem constructed_(t_'f or Repaired
by ----------J----.................... .............. .......... t, --- W_<_
----- ----- ...... ..... ...........................
S7Installer
at.............. ... -------_------_- ---------- ...... LiZ� ----------------------------------------------- .........
has been installed in accordance with the provisions of 'LIT—'-- 5 of The State Sanitary Code as described in the
application for Disposal Works Construction Permit No ----------------------------------------- dated___.__-___._.___._...........____.._._._........
THE ISSUANCE OF THIS CERTIFICATE SHALL NOT BE CONSTRUED AS A GUARANTEE THAT THE
SYSTEM WILL FUNCTION SATISFACTORY. I -N
DATE._.......--- `-----•........................•------------- Inspector ..... ....................... ........ ....................... ................
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