HomeMy WebLinkAboutApp-Permit-ComplianceNd-FEE. '
THE COMMONWEALTH OF MASSACHUSETTS
BOARD OF HEALTH
yJZ24no d
, pphratiun -fur Uwpooal Worko Tour i rixriinn Vrruift
Application is hereby `made for a Permit to Construct ( ) or Repair ( ) an Individual Sewage Disposal
System at
.item at : 1 '.. i x�v%4_ :- #..y4 v&------------- 477 *_ J -------_----------
Location -Address � l�Qt'L1 Lo ...
'Ial��riG%v Te_SI.L_.%�G Q '„ ...
ler
AddressPQ W
Type of Building
Size Lot14__.$7+,� . �Sq. feet
Dwelling No. of Bedrooms ----- lf ...........................Expansion Attic Garbage Grinder (—)
P`-1-1 Other —Type of Building _.---------- `-.____..__.- No. of persons.___..___'__._...____. Showers ("j — Cafeteria � )
Other fixtures .-_____." ______________ _ _
W Design Flow ........... . ......................gallons per person per day. Total daily flow ------- ZZ.0------------------------ gallons.
P4 Septic Tc11k— iquid capacitv-fUW-gallons Length."'"---------- Width_ ..._...._._ Diameter .."'____..__ De'tll_- _ __._ _
�� _- Width .... W--------- Total Length ----- Iirs_�------- Total leaching arear�3_,4, ft.
Disposal — No __________ __ _
Seepage Pit No...-___°�'-____.-.___ Diameter ---___"'___._.._ Depth below inlet._.... ".__._._. Total leaching area__...__'—____.__sq. ft.
Z Other Distribution box (�() Dosing tank (-_. *
~' Percolation Test Results Performed by__.T�_�___ .-._ ...._._. Date....7'' 8C�
--- -•---------------
a
-------------•--��----• - - - of
Test Pit No. 1 _.... :_minutes per inch Depth of Test Pit____ ..._. Depth to ground water..-. _ 4------..__..
(i Test Pit No. 2... Z...... minutes
er inch Depth of Test Pit ----- 9A --____ .- Depth to ground water____9---
k----------
xr-----------------
0
cription of Soil--- --'---.t1��-�ii✓��ft�!Y.�'?��f#_?�-_� ................. ---------------- j------------------------------ -
W------------------------------------------------------------------------------------------------------------------ -----------------------------------------------------------------------------------
UNature of Repairs or Alterations — Answer when applicable ------------------------------------------------------------------------------------------------
------------------------------------------------------------------------------------------------------------------------------ !i
Agreement :
The undersigned agrees to install the aforedescribed Individual Sewage Disposal System in accordance with
the provisions of Article 0of 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.
4----------------------
Sig d..__ - ... f �G to
Application Approved By__?'_... ----------------------------------•----.---•- p IX�*
Date
Application Disapproved for the following r sons:.----•----•------...---•----------------•------•-•-----••-•-----------•--------••--------..-._.-----•-----------
---------------------------------------•-------------•---s---------------------------------
Date
PermitNo --------------------------------------------------------- Issued ............................. ----------------_-------
Date
THE COMMONWEALTH OF MASSACHUSETTS
BOARD OF HEALTH
.......................................... OF .....................................................................................
(Irntif irate Lit f"untpliaurr
THerS
TCE TIFY,That the Individual Sewage Disposal System constructed K or RepairedY....--•---.
rL-------•---------------•-•-•-----•-- -------•-----•--•------•--
,�� i� Instal r � `
at ............. -------- --- l ••. L�Lf',�eL� -- /1�� /
has been installed in accordance with the provisions of Ar �XI ofryryTl�State Santt< it C�1 as des 'bed in the
application for Disposal Works Construction Permit No__________________r�G�--_---____-_-- dated_.______!7'._.-.--_--
THE ISSUANCE OF THIS CERTIFICATE SMALL NOT BE CONSTRUE® AS A GUARAN EE THAT THE
SYSTEM WILL FUNCTION SATISFACTORY.
VZ
tL
0i
DATE.................................... -----_---------------------------------- Inspector----------