HomeMy WebLinkAboutApp-Permit-ComplianceNo..�/:n Fzic �5'—
THE COMMONWEALTH OF MASSACHUSETTS
BOARD OF HEALTH
.. .........LOWIn ................ OF .... CLMOmA
Appliration for Disposal Murky Tonstrurtivit lirrutit
Application is hereby made for a Permit to Construct or Repair (SX—) an Individual Sewage Disposal
System at:
LDT L
..... L4?uaas ... a M
......... ............................................................. ............
logt1ion- Address or Lot
;Z 3 C3 ?0
.. ..................... AmAal-& -A UsnA ... . ......
Owner Address
..... PC.12? .... ............ ---i. 4m�
---►a-di n..;5 I L
------------------------------------ ---Installer--- ...... ...
Address
Type of Building Size Lot ............................ Sq. feet
Dwelling —No. of Bedrooms .............................. 2 ----------- Expansion Attic Garbage Grinder
04 Other —Type of Building ............................ No. of persons._.._.._......._.__._...___. Showers Cafeteria
Other fixtures .........................
Design Flow ............................................ gallons per person per day. Total daily flow -------------------------------------------- gallons.
Septic Tank —Liquid capacity ............ gallons Length ................ Width ................ Diameter.............__. Depth..._............
Disposal Trench — No ..................... Width...--......_._._._._ Total Length .................... Total leaching area .................... sq. ft.
Seepage Pit No ...................... Diameter .................... Depth below inlet .................... Total leaching area .................. sq. ft.
Z Other Distribution box ( ) Dosing tank ( )
1.4
I. -I Percolation Test Results Performed by .......................................................................... Date ........................................
�4 Test Pit No. I ................ minutes per inch Depth of Test Pit.__........._......_ Depth to ground water ........................
fT4 Test Pit No. 2 ................minutes per inch Depth of Test Pit...__......_......_. Depth to ground water.__..........__.........
Descriptionof Soil .................................................................................. .....................
.......................................................................................................... ...... ......................................................
-- -- -- -----
Nature of Renairs or Alterations — Answer when applicable.-Av P V . .. ..... t470�9
_Z4w 11L�.Qmk --- W.�.6t*.tst --- OLb ... tl�tSA.fir.-J ..................................
.........................................................................
Agreement:
The undersigned agrees to install the aforedescribea Individual Sewage Disposal System in accordance with
the provisions of T I A' LF, 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 the board of health.
Signed....---- ........ i7��-.L' ;'-a ....... --- ... ........
---- --- ----
_'6"" ehsons.:-'____X .................................................................................................
at
Application Approved By .............. . ....... . .......... ............................................... ....
.......... /
ate
Application Disapproved for the fol fowinga r ------
......................................................................................................... I .......................................... ................. .................................
Date
Permit No.__96 ....................... Issued- --------------- ft.........
............
e
THE COMMONWEALTH OF MASSACHUSETTS
BOARD OF HEALTH
............ -� .................... 0 F ....... �_� Ce'rp. 10Q.4
... .... .. ..............................................................
Qlrrtffirat of Tomphaurr
�HA,SS TO CERTIFY, That the Individual Sewage Disposal System constructed or Repaired
b3.. .................................................................................................................................................................................
AD Installer
at. o ... .. 0
.7 .....
.................................................................................................................
�
has been installed in accordance with the provisions of TWLE7" I of The State Sanitary e, described in the
(0 , 5-��
---- ----------------------------------- .....................
application .for Disposal Works Construction Permit No.
THE ISSUANCE OF THIS CERTIFICATE SHALL NOT BE CONSTRUED AS-jy7G1U, RANTEE THAT THE
SYSTE7_'W . ,FUNCTION SATISFACTORY.
K,
DATE! .... C .................. ... 0. Inspector ..... . ..... ...................................
11 -Y ---- I ----------................................