HomeMy WebLinkAboutApp-Permit-Compliance r WIN— -f
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No.__.tlI°17... FEB/� •
THE COMMONWEALTH OF MASSACHUSETTS
1/4______, BOARD OF HEA TH
G'
1 ` t 1 OF :...
A4Wiirution fur Elihuooa 1111'irks Cltonutrurti n Verutit
Application is hereby made for a Permit to Construct ( ) or Repair ( an Individual Sewage Disposal
System at:
s I, c.e .12 .0q ,L. ,ADT-1 97
/S �u4 ._.. 4.Q.Ar &e
ll
- ress 1 / or Lot No. Q.
.. 0 ."...e.._ iii, 1 e %/, 1}-. 1 wi ` 3
W is OwnereAddress
///��� Installe
Address
1 U Type of Building Size Lot Sq. feet
Dwelling—No. of Bedrooms ...._? Expansion Attic ( ) Garbage Grinder ( )
I a Other—Type of Building No. of persons Showers ( ) — Cafeteria ( )
Other fixtures
W Design Flow gallons per person per day. Total daily flow gallons.
W Septic Tank—Liquid capacityllMtxgallons Length Width Diameter Depth
Z Disposal Trench—No. Width Total Length Total leaching area sq. ft.
Seepage Pit No Diameter Depth below inlet Total leaching area sq. ft.
z Other Distribution box ( ) Dosing tank ( )
Percolation Test Results Performed by Date
Test Pit No. 1 minutes per inch Depth of Test Pit Depth to ground water
(s, Test Pit No. 2 minutes per inch Depth of Test Pit Depth to ground water
0
Description of Soil-.-., azM r- .,C.a.z r/
W
UNature of Repairs or Alterations—Answer when applicable. 4 SL2z..J /4za ex./ gT'
-.e„etom-► 1_. zsa J?Lr- (.60`- .s•-r e_k.A I` •---C,.19c&6'‘,,,
A eement:
The undersigned agrees to install the aforedescribed Individual Sewage Disposal System in accordance with
therovisions of TI'�'I.:T
p 5 of the State Sanitary Code—The undersigned further agrees not to place the system in
{ operation until a Certificate of Compliance has bee. issued by t - board of health.
4OFIig�' ' 'air .. Y/7/61.6
.ii ��'
Application Approved By ..-, ' ,..../ VIII
� -• Da
I •
Date
Application Disapproved for t following reasons:
/ 17 / Date
U 1'•�0 e
Permit No Issued_
Date
THE COMMONWEALTH OF MASSACHUSETTS
-.}------' BOARD OF HEALTH
'�• O Fwi 0--;�c--t
Trrtifir of aiuutpiianrr
by
TIMIS IS TOLE�R�TIFY, That the Individual Sewage Disposal System constructed ( ) or Repaired (z-3
at_./-5.6 & :!.L & ,c71,1er 4A-4
,
has been installed in accordance with the provisions of TIT 5 of The Stale Sanitar Code
y as described in the
application for Disposal Works Construction Permit No 7 7 dated
THE ISSUANCE OF THIS CERTIFICATE SHALL NOT BE CONSTRUED AS A GUARANTEE THAT THE
SYSTEM WILL N TION SATISFACTORY.
DATE r 7 ..•84 Inspector