HomeMy WebLinkAboutApp-Permit-ComplianceNo. tKe3....-.. Fm3.. 35.. ...............
pJ�yV� THE COMMONWEALTH OF MASSACHUSETTS
99Cj7- 3g BOARD 9FI HEALTH
O�........... OF ...........
'/�/�',t„�.v
Appliratimt for N-Opo-qttl Wor1w Tanatrnrtinn Frrmit
Application is hereby made for a Permit to Construct ( ) or Repair ( ) an Individual Sewage Disposal
System at
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................
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.�Locatimr -Address �+�'
?1N63; -L •-7 G�.�d"^=i� •✓✓ ...Jp rJ! B7° tNo� Gg/i;GL F?UJ::J9
. '........ Y .............. - :.....
Omncr Addresres s
Installer Address 15
Type of Building Size Lot1...i..................Sq. feet
Dwelling—No. of Bedrooms... ........ 3 ..... .......Expansion Attic ( ) Garbage Grinder (�fv
Other —Type of Building ............................ No. of persons............................ Showers ( ) — Cafeteria ( )
Other u s ............... ...... -------------------------.......-------
.. l�"��;"i.............................................. � cam.
Design Flow .................. ........... ......---.-- all ons per person p rlda°. Total da 11y flow ........... 5...:.................gallons
Septic Tank — Liquid capacity allons Length......... idth.. Y }!.p.. Diameter. ............... Depth ... r E...
Disposal Trench — No. . ... ...... Width ..... Total Length............ Total leaching area. .............. .-5q. ft.
Seepage Pit No-------- --------- tameter........ .. Depth below inlet ......._�4........ Total leaching area_ ...r..Sq. ft.
Other Distribution box ( � Dosing tan )r j /j /i r9 �� Z �5 -
Percolation Test Results ,—, Performed b..V...:.....C../.....�.j........ Date...... ............. f.
y..... ... / �t r-------------- Y
Test Pit No. 1.... f �.mmutes per inch Depth of Test Pit...._-�eS4 ,,. Depth to ground water...... '.0 _
Test Pit No. 2_ ..............minutes per inch Depth of Test Pit...l.............. Depth to ground water.7...................
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 TITIL 5 of the State Sanitary Code — The undersigned further agrees not to place th sys em in
operation until a Certificate of Compliance has en ived by th hes
board of ijt p
Application Approved By K da�isPt P ...................... .................. l /c4 (Pat
Date
Application Disapproved for the following r ons:.........-----........................................------.....................--......-----------
/ Date
Permit No..16.6_65i�J..�................................... Issued C...S1Y�...... 9
nate J
THE COMMONWEALTH OF MASSACHUSETTS
BOARD-75'
l�W �
we l ir'•l,.9.'t�r-/
tifirtttr liff�nmplianrr..........................
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THIS I�TOVERTIFY, That the Individual Sewage Disposal System constructed ( ) or Repaired ( )
=pl IFd.) rIS S!.j.4lC�
.....................................................................................
y ............._....... _................... .................
........... Installer
at.. -' ----- ........... ...... ................. .................... .--....... ....................................................
has been installed in accordance with the provisions of T�T,IE 3� f The State Sanitary �gile described in the
application for Disposal Works Construction Permit No.C.?.....''C. .................... datedlC fj<`?. df:............................
THE ISSUANCE OF THIS CERTIFICATE SHALL NOT BE CONSTRUED AS A S9 TEE THAT THE
SYSTE.....LL FUr7.V--•NCTION SATISFACTORY.
DATE... �.1-------------•••.......................... Inspecto ��S Q...... - - ..... .