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HomeMy WebLinkAboutApp-Permit-Compliance<9 NO.D.-: Fms/,-. t............ ` THE COMMONWEALTH OF MASSACHUSETTS BOARD OF HEALTH ........106017�....._....----- OF .............f� r `r ..... Appitra#ion for Disposal Works Tontitrurtion Frrutit Application is hereby made for a Permit to Construct (J or Repair ( ) an Individual Sewage Disposal System at: nn , 4z ...6* West U�............ ..•...---------- jf-fb°p7�................ tion _ Address r /h'ae............... ..-•----- �4 Wa ._._....- r --------------------------------------------- Zdmsr wner_.•......�Installer Address Type of Building Size Lot... /5 Q ....Sq. feet U Dwelling — No. of Bedrooms ............. ..________..____..___..__Expansion Attic ( ) Garbage Grinder ( ) 'L Other —Type T e of Building ............... No. of persons ............................ Showers ( ) — Cafeteria ( ) W yP g P Other fixtures -------••••---- -----•----------------------- W Design Flow...........................................gallons per person per day. Total daily flow ............... .Z a..._..........gallons. 9 Septic Tank — Liquid' capacity l®QQ-gallons Length ................ Width ................ Diameter ................ De h ................ W Disposal Trench — No. ____-1........... Width ... Z...._...... Total Length ..... lZ._...... Total leaching area ...%©.----- sq. ft. x Seepage Pit No ..................... Diameter ............. _...... Depth below inlet .................... Total leaching area .................. sq. ft. Z Other Distribution box (X) Dosin tank ( ) ,L�or l)ocun '-' Percolation Test Results Performed by. v%�n_!!I/- ...................... /':---__ Date ...... 9 aTest Pit No. 1...:5�___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 ........................ -------------•-------------••-------•---•-------•---------------------------- --------------------------------------------------------- Description of Soil _.'-.�:_��� tl_..L oct �65os-�----------------------------•-......-----------••----------•------------•---------------- - - 7 �- /L%o!/u.►n-.��.. GD¢rs_-s2�d-f-.r,t!�....-------------------••-------------- 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 TITI.L 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 b;4h eboard health. // y....................... ________ ____________ Application Approved By.i =------- - ------------•--•-------------. i�,S b Date Application Disapproved for the f ollo ing reasons-------------------------------•----------------••---------...---------•-----•--. ----------------------------••---------------•----•-•------------- -•----------------.......----•--------------------------------------•---------------------••------,...-------------------••-------- Date PermitNo --------------------------------------------------------- Issued .--------------_----•----------------------------------- Date THE COMMONWEALTH OF MASSACHUSETTS BOARD OF HEALTH ......... o�:.................................................................................. Tri4ifi tt r of Tootpliatta THIS IS TO CE T F - , T the Individual Sewage Disposal System constructed (_�) or Repaired ( ) f... -------------------------------------- by ................ • -- % � / Installer � G at... 11 �= �' � '" .... -__: -----•----••--------.... = ----- ------------------------------------------------- has be n installed in accordance with the pro sions of TITL, 5 of The State S ary Code as described in the application for Disposal Works Construction Permit No.. yl� ___��--. at d__._—----- THE ISSUANCE OF THIS CERTIFICATE SHALL NOT BE CONSTRUE® G ARANTEE TTHE SYSTEM WILL FUNCTION SATISFACTORY. DATE .......... '�� `.... .......................................... Inspector. ............. ... ........•-------...------•----•-••-------------.-----