HomeMy WebLinkAboutApp-Permit-ComplianceTHE COMMONWEALTH OF MASSACHUSETTS
BOA, RD OF HEALTH
........... T.6 --- W.0 ....... OF ...... ')1Al2.AA0_U__-T.77.4 .......................
Appliration for Disposal Works Tonstrurtion jhrutit
Application is hereby made for a Permit to Construct or Repair an Individual Sewage Disposal
System at:
I�OT 1�Vq
............. .... ............................ j ........ 52!!��F S .. r .....................
Location , Address or Lot No.
2 ...............................
........... . ..... dro-14CP-17--r ---- i --- C5.V_X ------ 4 ----- :P.OA444*4:�.
owner A/dr-ess
'A _r r3o.C?-172 — _F
.... r
.............. . ........ ... 4--plua.? P.P4.-J.-V ......
Installer Address
Type of Building Size Lot...11._2177 Z....Sq. feet
Dwelling —No. of Bedrooms._ --... ............................Expansion � Garbage Grinder- f j
Other—Type of Building ............................ No. of persons ... 4 --------------------- Showers (Z) — Cafeteria
Other _fIxtures -------------------------------------------------------------------------------------------------------------
2 --------------------------------------
Design Flow ........ .. ..--------------------------gallons per person per day. Total daily fl Z 0 ............ w ---- gallyns.
Vy 0
Septic Tank — Liquid'capacity-19M.gallons Lengthli.�.fa.� Width.!1�i -a- -in --- e_t_e__r__'__ ------ Depth ... 4 -- --------
Disposal Trench — No ..................... Width.._................. Total Length._.................. Total leaching area .................... sq. ft.
Seepage Pit No ------- I ------------- Diameter ....... 5 ......... Depth below inlet..... 69.1....... Total leaching area ... 2 ± sq. ft.
Other Distribution box Dosing tank
Percolation Test Resuld"" Performed by ----- .--- Date ........ ......
Test Pit No. L.!4!2v� .. minutesperinch Depth of Test Pit.... 1.1 ............ Depth to ground water ....... jl.-- . .......
Test Pit No. 2 ................minutes per inch Depth of Test Pit.................... Depth to ground water ........................
... ................................
114
Description of Soil ....... ........... .
.... ......... .. .... .................... w .................
....................................................................................................................................................................................
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 TLITI-E, 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 board of hea
Sig ....... ....... - 10'.
............ Z_f ------
a e
ce !� 047
Application Approved By ........................... D -CA -9 -tom- ----- A - -- ------------------- ........ -- - --- ------ 7.� --------
Date
Application Disapproved for the following reasons:........
........................
Date
PermitNo ......................................................... Issued ................. .....................................
Date
THE COMMONWEALTH OF MASSACHUSETTS
BOARD OF HEALTH
....................................
................. ............. OF ...... ;' ' '*
(9rdifiratr of Toutpliattrr
THIS IS TO CERTIFY, That the Individual Sewage Disp?sal System constructed O or Repaired
by------- ...........................................................................
Installer
at .................I
( ...........................................
t 4tj_.' -
has been installed in accordance with the provisions of TIT IF 5 of The State Sanitary Code as desgribed in the
application for Disposal Works Construction Permit No.- ....... dated ..... - 7 5�
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THE ISSUANCE OF THIS CERTIFICATE SHNOT BE CONSTRUED AS A G RA "EE THAT THE
SYSTEM WILL FUNCTION SATISFACTORY.
DATE................................................................................ Inspector