HomeMy WebLinkAboutApp-Permit-ComplianceNo..---. �1....Za�/ FEB.... 5.� .......
THE COMMONWEALTH OF MASSACHUSETTS
' - fB� IOARD OF HEALTH
_T._ 02..W1.4.-----.OF............Y40N1:ZM.Z?-U------------------------------
Appfiration for Di -epos l Workii Tomitrnr#inn rgmit
Application is hereby made for a Permit to Construct or Repair ( ) an Individual Sewage Disposal
System at: /
.......,�. - .. 1. Tl.. -. 1L JFw ............................................................ Ce-----•------------------............----•-
ocation - ddress or Lot No.
- [ :e ':-5. c..� �_ �✓ i _��rt�s1!' .. i�°� ._ ... L .1 _c s i �r� �. Z!n 4----
Owner ddre s
V N ►T�
------..••-- �..
Installer Address
Q Type of Building Size feet
Dwelling — No. of Bedrooms_ ..... ;L ............................... Expansion Attic ( ) Garbage Grinder ( )
Other — Type of Building ............................ No. of persons ............................ Showers ( ) — Cafeteria ( )
P, Other fixtures ---------------_---_-----
-----------------------•--------------------------------
W ign g 8 - .7 -• - -y-••� 0 -----------dons.
Desi Flow---••---------) -1_-¢ ------------•------- gallons erg-�s�rl' per da�. Total daily flow----------------------•---- - -
WSeptic Tank — Liquid capacity. QP.Ogallons Length._6.-_.(V.. Width' -.'__1.O' Diameter ________.•_-__ Depth_5_".+.'_.
Disposal Trench — No_ _______________•---- Width .................... Total Length .................... Total leaching area .................... sq. ft.
Seepage Pit No --------- I :Q
._________ Dia eter.......�._ .... Depth below inlet --- L ---_-------- Total leaching area.. i0_.I.sq. ft.
Other Distribution box ( Dosing tank
Percolation Test Results Performed b ._- �s.a...'. __ .��%�/� �._�._~..�_%.'__?t_.
Y �"�-=--�---`----`-- =•.------•----------- Date.----
a • Test Pit No. 1 ---_--.__mutes per inch Depth of Test Pit ... 1 . t ... Depth to ground water ........... --__.........
Test Pit No. 2................minutes per inch Depth of Test Pit --------------- Depth to ground water ........................
...---•••----------•----•-----------------------------•----------------------•-------------------.........----...•.
Description of Soil . --Q -------IPPA? --y�----- '+.------`�--- l --------------------------------- ----------------
U
W-------------------•-••---•---------------------------------------•-------------•-------------------------------------------------•---------------------------------------------------------•-_---------
UNature of Repairs or Alterations — Answer when applicable................................................................................................
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Agreement:
The undersigned agrees to install the aforedescribed Individual Sewage Disposal System in accordance with
the provisions of TITL% 5 of the State Sanitary Code — The undersigned further agrees of to place the system in
operation until a Certificate of Compliance haseen 'ssu by the board of healt
Signed
Date
Application Approved By ...:........... 2
Date
Application Disapproved for the following reasons:-----------------------------------------------------------------------------------------------
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Date
Permit No........ EL. Z ��---------------------------- IssuecL------- ez......................
Date
THE COMMONWEALTH OF MASSACHUSETTS
BOAYDF HEALTH
.'`'i.�.......... OF.�' � ...............................
(gatifiratr of Tomptiatta
THIS IS TO CERTIFY, That the Individual Sewage Disposal System constructed (4 -<or Repaired ( )
by----------------- '..)_,_ .......! %'------------- ---•-----------------------------•-------.......------------------------------------------.-------•--
at------..... La........... .. .. ---f_�Ci� �; --Installer---------------------------------•-----------.....---•--------......----------------------•-.
has been installed in accordance with the provisions of TITS 5 of The State Sanitary Code as described in the
application for Disposal Works Construction Permit No..... --------- __-_-_-_-•___-___• dated _,.-----
THE ISSUANCE OF THIS CERTIFICATE SHAM NOT BE CONSTRUED AS A GUARANTEE THAT THE
SYSTEM WILL FUNCTION SATISFACTORY.
DATE ............ 7.__ Inspector--_---. ---- _