HomeMy WebLinkAboutApp-Permit-ComplianceNOR—
THE COMMONWEALTH OF MASSACHUSETTS
BOARD OF HEALTH
_77.a -.w . w....-...... OF ........ y.. ........................................
Appl ration for Disposal Warks Tonstrurtiun Errant
Application is hereby made for a Permit to Construct ( ) or Repair (L,) -an Individual Sewage Disposal
System at:
............ _...�Y1. 1°` :�s .....:�0..... ........ .....
tion - Address
........ `.►-� ........... .i. k�1.�2.A..d.....................................
.� �o
Installer
X 39
............ LV-,_...y...AR1en.Q. .. ...... I ... ...........
p ,/� or Lot No.
Address ^µ.,�—
.......... __»4� �!�::!1.� ::S_......P.LL�': ril ................. .
Address
Type of Building Size Lot ............................ Sq. feet
Dwelling —No. of Bedrooms..... 3..................................Expansion Attic ( ) Garbage Grinder ( )
Other — Type of Building ............................ No. of persons ............................ Showers ( ) — Cafeteria ( )
Otherfixtures--•---•---•--------------------------•---------•---....------------------•--...---------------....----------....------------------•-----•--.....-_....
Design Flow ........... .......................gallons per person per day. Total daily flow...... . ...................gallons.
Septic Tank — Liquld ca.pacityLOf.,D..gallons Length .............. Width ..... q.(.... Diameter.......--....... Depth ................
Disposal Trench — No ..................... Width .................... Total Length .................... Total leaching area ...................sq. ft.
Seepage Pit No ------- I ............. Diameter ...... LS/ Depth below inlet ...... IC/ ..... Total leaching area .................sq. ft.
Other Distribution box ( ) Dosing tank ( )
Percolation Test Results Performed by.......................................................................... Date ........................................
Test Pit No. 1..............minutes per inch Depth of Test Pit.................... Depth to ground water........................
Test Pit No. 2................minutes per inch Depth of Test Pit.................... Depth to ground water........................
Descriptionof Soil ..................................................................................
.......................... -✓------------------------------------------------------------------------------------ /
Nature of Repairs or Alt rations - Answer when appli ble�.�"1 ..........�_..._.. S?......�� .. l.k'r I'!�%.
Oa
Agreement: 3 FAO LPO M5ae s
The undersigned agrees to install the aforedescribed Individual Sewage Disposal System in accordance with
the provisions of TITLE 5 of the State Sanitary Code — The undersigned further agrees not to place the system in
operation until a Certificate of Comp ' the bo o health.
ApplicationApproved By .................... • .......... ......... ....................................... ....... .. -•--••--
D e
Application Disapproved for the following re ns: ............... -.......................................................................................... ......
•-••---••-----...----•-------------•-•---------.....---••---.......---•---•------•------•---•-----------•.•--------------•-------------•--------•-----...-------•---: .. --
rr��� o
Date
Permit No..7:..............................._.... Issued. ... _....l..1..:............
_.ter - -- -- _ _ _ - -- -- -- - _ - -- - -- - - ---- - -- - __ -- -- - _ - -- - - - - - -. _ _ - - _ _ . ---•�------ THE COMMONWEALTH OF MASSACHUSETTS
BOARD OF HEALTH
..0.5.9._ .i .........OF... I ..........................F..................
(Irrtifirate at froutplittnrr
THIS IS TO CERTIFY, That the Individual Sewage Disposal System constructed ( ) or Repaired ("
by........................ .............. `F. ... ..! ..... -........................................................ .........._
Installer
at......................................:�` . Z--.----- giFl� :Y ./t_.�1:3:.. ......... �'.Iv .......... Cl._.4 7[Z.Gd! .+xt..........-•----.....................------
has been installed in accordance with the provisions of TITLE g of The State Sanitary C de escribed in the
application for Disposal Works Construction Permit No.f 1.7j95 ...................... d: ....................
THE ISSUANCE OF THIS CERTIFICATE SHALL NOT BE CONSTRUED AS",G ANTEE THAT THE
SYSTET WILL FUNCTION SATISFACTORY. "--- ------ -�
................................. Inspector..........• -..2P../.; .......... .• ..... ......................