HomeMy WebLinkAboutApp-Permit-ComplianceTHE COMMONWEALTH OF MASSACHUSETTS
BOARD OF HEALTH
!---------------------OF.....y/i..rc.'AA f
Appliration for Dhopmal Works Towitrurtion Frrutit
Application is hereby made for a Permit to Construct (X) # Repair (X) an Individual Sewage Disposal
System at: G A 1
_ ''r 1. t-��-------------------------------------------
.
,
--- • L GX .._....? .............� �?M.P.. ..............j LC44--•--••-----.....................-•--� • -- - .._..........
Location - Address or Lot No.
............................................
Address
G aInsler 7 Ly a Address
Type of Building /f Size Lot ---------------------------- Sq. feet
Dwelling — No. of Bedrooms..........: .............................Expansion Attic ( ) Garbage Grinder ( )
Other — Type of Building D? .v •Lrt IAIA�---- No. of persons ............................ Showers ( ) — Cafeteria ( )
Otherfixtures --------•--...--•---•---•-----------------------------.-------------------------------------------•---------------------•--•---------..._..-----------
Design Flow ........ _ 50..........................gallons per_pw-T,day. Total daily flow____, *�_............._..._._...._...gallons.
Septic Tank —Liquid* capacityfv4 2.gallons Length .... '_......... Width ... .'y_....... Diameter ................ Depth.—I ...........
Disposal Trench — No ................ ... Width .................... Total Length .................... Total leaching area ... 17 .........sq. ft.
Seepage Pit No ..................... Diameter.................... Depth below inlet .................... Total leaching area .................. sq. ft.
Other Distribution box ( A) Dosing tank ( )
Percolation Test Results Performed by._✓V44._ 1 _ __ .f� ,z :.... 1 aY $Date --------------------------------r----.
Test Pit No. 1.!!� _4..._._minutes per inch Depth of Test Pit ....... Z ...... Depth to ground water ..__'V.ZZ.........
Test Pit No. 2................minutes per inch Depth of Test Pit .................... Depth to ground water ........................
------------------------------------------------------------------------------------------------------•------------------- ---------------------------------
Description of Soil..... htamafn ....... /tl!?--------- '� �------..._.�� c' f------- !_LR., ------A. .r ...............................
........... 59._7._r..---•--........e.F, :r.---------- ....---- 03g'T4:UJ..... .------------------------
................................. =..................................................................................................................... ................................................
Nature of Repairs or Alterations — Answer when applicable ....... A?,WW4e�,_-___._ _AUY,�?
ZlV ` C E C%!?..... .-------.fr'fi i ........... ......... 1? tT y 1!Y�z'.r s .............
Agreement: ,r �� lC 7'� } .h�®G js
The undersigned agrees to install the aforedescribed Individual Sewage Disposal System in accordance with
the provisions of TIT1 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 by the board of health.
Signed ......
Application Approved By ...........................................
Application Disapproved for the following reasons:
Permit No.
Date
Date
....................
Date
Issued.......................................................
Date
THE COMMONWEALTH OF MASSACHUSETTS
BOARD OF HEALTH
............. I............................ OF .....................................................................................
Grtifiratr of Tomptiaurr
THIS IS TO CE .TIFY, T�liat the Individual Sewage Disposal S stem nstr ted ( ) or Repaired ( )
v'Gt
bTom_ _ _-----------------------------------------------� -- ------
y
Installer
at--------------------------------------------- .................... --------------------------------.--.-------.-----------..---------------------
has been installed in accordance with the provisions of TITLE r 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. -4 .0
DATE...................../.� L L �. 75 ................................. Inspector ....................................................................................
N