HomeMy WebLinkAboutApp-Permit-Compliancep
81-73
No.........................
THE COMMONWEALTH OF MASSACHUSETTS
BOARD OF HEALTH
...................... W1C?T&.---......OF.....-----..YAI7MQI,TT-H..
Appliration for Disposal Works
Application is hereby made for a Permit to Construe
System at:
14vw L, Am WT
cation - LAddress
,- - .._..��-�-......................................
�p Owner
WVt Qa... ...................
Installer
(X ) or
F,m.......25.00
F
Ton#rurtion "permit
Repair ( ) an Individual Sewage Disposal
LD T� 7 m nig- 26
...............................................................
or Lot No.
.......... ..........................................................
Address
Address r
Type of Building Size Lot.Os.k=.Sq. feet
Dwelling —No. of Bedrooms ......__..•.....-�.................... Expansion Attic ( ) Garbage Grinder ( )
Other — Type of Building ............................ No. of persons ............................ Showers ( ) — Cafeteria ( )
Otherfixtures -------•-------------------------------------•--•-------•-----------------•-----------------------•-----------------------------•-•------•------------
Design Flow ............................................ gallons per person per day. Total daily flow ..-_...._...`!2_ ............... gallons.
Septic Tank — Liquid capacity-: R-1k.gallons Length ................ Width ................ Diameter ... ............. Depth ................
Disposal Trench — No. -------------------- Width..r.................. Total Length -------- ----------- Total leaching area ...... _.__......_sq. ft.
Seepage Pit No ........... i........ Diameter ......... 1p....... Depth below inlet _.... /?_.......... Total leaching area' -.;k 1_7 ft.
Other Distribution box ( ) Dosing 5A4 ( )
Percolation Test Results Performed by ......... L... --- h4- I. ....................•..•... Date ._J_- nv.r.........
Test Pit No. 1................minutes per inch Depth of Test Pit ....... I ............ Depth to ground water ....................
Test Pit No. 2................minutes per inch Depth of Test Pit .................... Depth to ground water ........................
----------------------------------------------------------------------------------------------
Descriptionof Soil---------------------------------------------------------------------------------------------------------
---------------------------------------------------------------------------------------------------------
Nature of Repairs or Alterations — Answer when applicable
Agreement:
The undersignedagrees to install the aforedescribed Individual Sewage Disposal System in accordance with
the provisions of ITIT ?`. 5 of the State Sani*L4,t
— Thfe dersigned tl:e agrees not to place the system in
operation until a Certificate of Compliance had bybo d of 1 eal h.
igned.....................O
.
A lication A roved B -I
----- --------------------------------- ------•-----.`_®_..,•-----
PP PP y ----
ate
Application Disapproved for the f ollowin easons:---•------------•--------••-------------•------------•••--•---•--•------•-•--•-•--•---------•--••--.............
-•---------------••••----------•---------------------------------------.....•-•--•----•--•--------------- --•---------••-------------•------•-•----•---•--•-•--------•--•-•-----•-•--------------•---•---
Date
PermitNo --------------------------------------------------------- Issued .......................................................
Date
THE COMMONWEALTH OF MASSACHUSETTS
BOARD OF HEALTH
............................... OF........ YAlU'I�I
....................................................................
Tnrtifira a Vf Tamptittnrr
X
THIS IS TO CERTIFY, That the Individual Sewage Disposal System constructed () or Repaired ( )
b LOT 61 — HMAM) L i`JRTl -''•Y,
---------------------------------•--._...------------•--
C• D M Installer
at--'----------------------�------+----
----------------------------------- ---------------------------------------------------------------------------------------------------------------------------
has been installed in accordance with the "provisions of 'LIT I ft_hof The State Sanitary Cc l k/A scribed in the
application for Disposal Works Construction Permit No.._.....iil ............................. dated .._...._......,3.U___....L_..........................
THE ISSUANCE OF THIS CERTIFICATE SHALL NOT BE CONSTRUE® AS A GUARANTEE 7 HAT Tit �
SYSTEM WILL FUNCTION SATISFACTORY.
DATE... ' ......................................................... Inspector-- ....... . .................................