HomeMy WebLinkAboutApp-Permit-Compliancev24
0 7 a., u t I i .._, T.
South Yj- i-joj`hr
THE COMMONWEALTH OF MASSACHUSETTS
BOARD OF HEALTH
7'0�ZF..!�...r
122—
................................... .f
Appliration for Disposal Works Tonstrur#inn ermit
f
Application is hereby made for a Permit to Construct ( vT or Repair ( ) an Individual Sewage Disposal
System at :--
...
. -G_� ---:.?.•::..�. .....O... .✓i. . ve............ .L . _r o�Y
onA.
Locati..ddress . / Z j.? or CLotc
•- ��-fit'---:._� _ .... :' r.` 2�.t�1 ':s...
Owner Address
...._.... - - ---.......;x. -.... ................
Installer Address
Type of Building Size Lot--- Lt -,IA - z t Sq. feet
Dwelling —No. of Bedrooms.......................................Expansion Attic .�- " Garbage Grinder
Other — Type of Building ...._2e ?............ No. of persons ...._.... G :............. Showers k--)-- Cafeteria-e—y-
Otherfixtures^ r— ...........................•--•--------.............---•-••.....----
Design Flow ................... �-� o � gallons per person �per � ay. Total daily �flow ........... _..................... Q ._............gallons.
Septic Tank — Liquid' capaclty____...._.__gallons Length ...:............ Width_...._.._... Diameter......_..._..... Depth...........
Disposal Trench — No ..................... Width .................... Total Length .................... Total leaching area .................... sq. ft.
Seepage Pit No -------- 1........... Diameter ....l_......... Depth below inlet ...... � :.�. �-�-�'-
Total leaching area ...sq. ft.
Other Distribution box ( Dosing tank ��. _
Percolation Test Results Performed by....-_.._�1... l.P. :._.......L` 1./ D
�.r,ate..-------••- ---
Test Pit No. L. Z.—.minutes per inch Depth of Test Pit ..... _. Depth to ground water ...... ..2
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 undersigned agrees to install the aforedescribed Individual Sewage Disposal System in accordance with
the provisions of TITLZ 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 bo d of health.
DDtt�
Sig d .-• ... al eLA.. . --......I
✓ •-•---.......-•--- !.I. -` - :.��......
ate � .
Application Approved By ------•. ...--------•--••-. •l �f?l..�ifL-.,,1�l.�..._.
- /mate
Application Disapproved for the following reasons: ..............................................................................................................
-••------------------------------------------------------------------•---------------•-------------------.-------------...----------•--•----...-----.......-------------.............---------•-•--
Permit No d:.. ..` � ........................ IssuecL..�u�lf. .1._!�! ---
THE COMMONWEALTH OF MASSACHUSETTS
BOARD OF HEALTH f
........... �.. OF ....... �•- r' ra....�. ...........................................
Trr#ifirate of Toutpliaure
THIS IS TO CERTIFY, That the Individual Sewage Disposal System constructed Repaired ( )
by---------------------- C .Cr,........cmj n. ............................. •--•_-----------:... ..--•--.... •..... .......•--• .... .--------
Installer
at.... G. � , f 1l _ :. Sr' r R... �:
has been 'installed in accordance with the provisions of TITLE 5 of The State Sanitary Code as described in the
application for Disposal Works Construction Permit No _....._.....:_.._._.._ .I ............. dated................................................
THE ISSUANCE OF THIS CERTIFICATE SHALL NOT BE,C-ONSTRUE® ASA GUARANTEE THAT THE
SYSTEM WILL FUNCTION SATISFACTORY tr ( ���
DAT....... '/'l -2 .....::... - Inspector Q-:` . - ;t....1�. ---1 -�••--•--..•.-