HomeMy WebLinkAboutApp-Permit-Compliance' No......s.—ZG�� Fps....... .....
THE COMMONWEALTH OF MASSACHUSETTS
BOARD OF HEALTH
............. OF ...........
-
Appiiratiou for Bispoiiai Works Tomilrurtion tl�rnti#
Application is hereby made for a Permit to Construct (x) or Repair ( ) an Individual Sewage Disposal
System at:
.........------- T..N:!- �.....---cG- �, ... - IDT = 3 -rn �' �.� ..
,Location - ddress .� or Lot No.
u.t.�.,�LGs
C.Owner Address
I.. zt.Nt.(__...C1�1..:7.YtJ.I. [-Ll✓l t?:r..._.G� L�2i�1
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ID
Installer UN IT I Address
Q Type of Building Size Lot.aatS_;t,1tt... Sq. feet
Dwelling —No. of Bedrooms ......... rel...............................Expansion Attic ( ) Garbage Grinder ( )
aOther — Type of Building ............................ No. of persons ............................ Showers ( ) — Cafeteria ( )
Other fixtures ---------------------------------
W Design Flow gallons per�per day. Total daily flow ............. V gallons.
WSeptic Tank — Liquid capacityl_RO.O.gallons Length...'5._-&._ Width..I'1.0. Diameter______________ Depth_ -``?--_'.1'_.
Disposal Trench — No ..................... Width .................... Total Length .................... Total leaching area .._......__.....____sq. ft.
Seepage Pit No ............. 1....... Diameter ....... bo....... Depth below inlet ...... �_.___.. Total leaching area-... MR.1-sq. ft.
Z Other Distribution box ( L4- Dosing tank ( )
'-' Percolation Test Results Performed by....R - Q'H.F - .R&_..)_.)..N. _ ...... Date .......
as Test Pit No. L_ G._Zvnminutes per inch Depth of Test Pit ----- � "Depth to ground water ........................
1:14 Test Pit No. 2................minutes per inch Depth of Test Pit .................... Depth to ground water._..-:._._....__........
P4� �............................................................. ...................................... .........................................................
ODescription of Soil Q a. ---- T.0Fs;t1.1r._..... *..... .-----------------•-•---------------------- -------------------•-------------
w
U 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 TITHE 5 of the State Sanitary Code — The undersigned further agrees of to place the system in
operation until a Certificate of Compliance has been issu d by the board of health.
Signed--- ...... ,,,..... ---- — L s✓- x.
Application Approved By...... ..... ...... -----•........ _�-----1� - � �
--------------------------------------------------Date
Application Disapproved for the following reasons_ _________________ ------------------------....... _.____
Date
Permit No. ld.l---�--�-------------------------- Issued -------- 2 - 3d ^ .$`
Date
THE COMMONWEALTH OF MASSACHUSETTS
-�-�- BOARD OF HEALTH
........1... -' .......... OF..Y�'.r'filc�r1T" ..............:..............
upirrtifiratr of Toutpfiaurr
THISIS TO CERTIFY, at the ,Individual Sewage Disposal System constructed (L -<Or Repaired ( )
by....�?....... .. L.±L2 ------------------------•-------------------------------•-------------------------•--......------------------------.
Installer
atj-2 r ! ' �. Y C. ---•------------------------------------------------•-----•---------------------------------------------
has been installed in accordance with the provisions of TI`'" 5 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 CONSTRUED AS A GUARANTEE THAT THE
SYSTEM WILL FUNCTION SATISFACTORY.
DATE------..... ---------------------------- Insvector----- ._