HomeMy WebLinkAboutApp-Permit-Compliance! ) CV/�
No.../......( ............. / Fac................
..............
THE COMMONWEALTH OF MASSACHUSETTS
�7'' BOARD OF HEALTH
........TO,W. .V..........OF........ r wr.Q.Ci'L_l....._.............................
Appliration for Dwpo,>3ttl lgorkg TIMStrnrtion rrrmit
Application is hereby made for a Permit to Construct (>f) or Repair ( ) an Individual Sewage Disposal
(9) System at:
................ L..O`T .....�8..�............. CCnf %.Y..- .S'�u.'..t ....... /�K'vjtbu��l n�nP
.-�i
catioi A rLss int rze. .................
�x
C'.%1�' .....:.......!Y1�Y.�.....
Owner ... 3'.... .....lt�i�:�
Address
(sj L✓c
p� I sstaller Address
v Type of Building Size Lot./I.,18.9 .... Sq. feet
a Dwelling—No. of Bedrooms............. ..............Expansion Attic ( ) Garbage Grinder ( )
WOther—Type of Building ........ No. of persons .... Showers ( ) — Cafeteria ( )
d Other fixtures
W Design Flow ..................... ...... ......gallons per person per day. Total daily flow....................._.�........gallons.
WSeptic Tank —Liquid capacitylQ.O..P..gallons Length... -.(i" Width. .Vo.`! Diameter ................ Depth..:
Disposal Trench — N/o..................... Width.................... Total Length......../........... Total leaching area.............. sq, ft.
Seepage Pit No......../........... Diameter..G_!%/../... Depth below inlet....6.�........ Total leaching area.2.°�.�..�....sq. ft.
Other Distribution box (X) Dosin tank ( `
a Percolation Test Results Performed by... - 9Q.k?c4...4ow...d.(sI-ii�%��!iJ.✓." Date._UAlw Z(. „M1 et 7
N Test Pit No. ILM..;Z=n1inutes per inch Depth of Test Pit..J44Y ....... Depth to ground wate-r. P..._...... -'
G. Test Pit No. 2................minutes per inch Depth of Test Pit.................... Depth to ground water........................
x................................ ........... .
DescriationofSoil.....--_L±Si�__/4�1�k+ %Y7�'UlUcvt f'!tltic7 llnf�oFd- !J''''i...'-' ......... e,.,...."""""""
Nature of Repairs or Alterations — Answer when
Agreement ...... _..... -- -
------ ------ ...............................
The undersigned agrees to install the aforedescribed Individual Sewage Disposal System in accordance with
the provisions of TITLE 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 health.
Application Approved By ....... ................. - .............................. _................. Date
Application Disapproved for the following reasons:._.......................................................Dat.
Permit
THE COMMONWEALTH OF MASSACHUSETTS
BOARD OF HEALTH
Date
Date
.......................................... OF .................. ..............................................................
Tlez tifiratr of Tomplittnrr
THIS IS TO CERTIFY, That the Individual Sewage Disposal System constructed ( ) or Repaired ( )
Installer
has been installed in accordance with the provisions of TITLE j 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.
DA