HomeMy WebLinkAboutApp-Permit-ComplianceNo.. E.510 > Fzcs.....
THE COMMONWEALTH OF MASSACHUSETTS
BOARD OF HEALTH
®. ........... OF ...... Z //' e.77.1...........-•....................
Appliration for Disposal Works Tontrur#ion 1hrmi#
Application is hereby made for a Permit to Construct V) or Repair ( ) an Individual Sewage Disposal
System at:
�?. ......S��r':'_ .�.i ,Z.crig` -= `-Y .......... _ ap-..ia..._..........................................................
Location - Address or Lot No.
........ --................................. ---..........................................
Owner Address
mCYS,.t. kck -
Installer Address
Type of Building Size Lot ............................Sq. feet
U Dwelling —No. of Bedrooms............................................ Expansion Attic (�) Garbage Grinder (vo )
Other — T e of Building � 5........ No. of persons ............................ Showers — Cafeteria
Q' Other fixtures ------------------•----........---------------.......--------
W Design Flow.............4 ✓r..................... gallons per person per day. Total daily flow ...........✓�r? ®-...................gallons.
WSeptic Tank —Liquid* capacity/,.e%� .gallons Length S_.7 5..--. Width-' .-_6_.-__- Diameter ................ Depth- ¢.........
x Disposal Trench — No.Width..... 8.-`-........ Total Length ...... . r._...-. Total leaching area.... Gam..'_-sq. ft.
Seepage Pit No ..................... Diameter .................... Depth below inlet---................. Total leaching area .................. sq. ft.
M Other Distribution box (i/) Dosing tank ( ) 6 V30/9'7
Percolation Test Results -Performed by..................:....................................................... Date............... -ylt6- .
� `-----water- fey---;
Test Pit No. I.....2....._.minutes per inch Depth of Test Pit Depth to ground ...•..............sS��
(s, Test Pit No. 2...... Z....... minutes per inch Depth of Test Pit ...... d........... Depth to ground water .................
...................... - s .....................................................
O Description of Soil ................ O... --- Z...-------�- =; ---
v------------------/-- ``..6 Sf�X�G?.........----------------------•------------------------........-------•--•----------.....--...
W------..... � ...------•-•---------•-•--•-••---.
VNature of Repairs or Alterations — Answer when applicable ...............................................................................................
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Agreement :
The undersigned agrees to install the aforedescribed Individual Sewage Disposal System in accordance with
the provisions of TITLE 5 of the State Sanitary de — The undersigned further agrees not to place the system in
operation until a Certificate of Compliance has be i ed by the board of h h.
Signed . _ : ----•---.-----------•-----------------
--• - - -
ate U
Application Approved By....................
y--•-•.........:.....} .
ale ,r
D e
Application Disapproved for the following reasons: ..............................................................................................................
-
.........................................................................................................................................................................
Date
Permit No.......... ........... _.... Issued - (•............
i t 3 f i& *IX t a ► si ♦ f . , a . a , > ! , > ... 1 . . . . > J l . l ] . > >.. > . . a . > J +) Y ... ... ... . . .. . . i . . . . . . . . . . i i . i . . . . .. ... . . . . . . . . > > > > . . . . > .. > , i , , > > . i
THE COMMONWEALTH OF MASSACHUSETTS
BOARD OF HEALTH
......................... .........................
CIrrufira tr of Tontpliatta
THIS IS TO CERTIFY, That the Individual Sewage Disposal System constructed (0 or Repaired ( )
3 c � ��_`� l e_ Installer
at.---- ..----.... c7 — /_`.-�c-' I •. •'�- / %-/ =
has been installed in accordance with the provisions of TITLE 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 CONSTRUE® AS A GUARANTEE THAT THE
SYSTEM WILL FUNCTION SATISFACTORY.
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