HomeMy WebLinkAboutApp-Permit-CompliancerJi "Tr 1 (-!�EN_TH DEPT.
NO
�Y Town 0<< e vLlildInv
- P South Yarmoafih, .MA 02,664 rE$�
.................
THE COMMONWEALTH OF MASSACHUSETTS
-T BOARD OF HEALTH
......./ .OW Q ................. OF ..........
Yfi . !/..o rl%..........................................
Appliratiun for DWVviial 39urk i Tonotrnrtion Trrmit
Application is hereby made for a Permit to Construct (K) or Repair ( ) an Individual Sewage Disposal
System at:
k2Z�.� 721-l..I...... !f SE...... t?n!............. 1X --T- ..... f.......4 ..........
.:.... _�...
Lot or Lot � � n
p ^r^
'.aY3. -, eve .........l..rL�r�................................... ............. �!4crxe l..u.�L.aet............ R ...............R..l...�.✓ 1
e.---. OMs t� Address s ��
ti l_arwrt......Ca.,`elt..x.............................•--------. •A&m777tr....AL- &� f/-�x/>s�sArs+wca�...... ...
Installer Address
Type of Building Size Lot.
... LZ. 1.4.6 Sq. feet
Dwelling — No. of Bedrooms.......... 3..............................Expansion Attic ( ) Garbage Grinder ( )
Other — Type of Building ............................ No. of persons............................ Showers ( ) — Cafeteria ( )
Otherfixtures ...................... ___ ............................................ .......... ............ ............... ................ .........................
Design Flow ........ 6.,5 ............................gallons per person per day. Total daily flow.......... --- Gs'. ................ ...gallons.
Septic Tank — Liquid capacity/P.00.gallons Length....h..t'........ Width ... 4......... Diameter ................ Depth.......:....
Disposal Trench — No ..................... Width...................: Total Length.................... Total leaching area..,. ................ sq. ft.
Seepage Pit No... ...... I......... Diameter...lzi. _ Depth below inlet .....ff.:........... Total leachingarea. zrh t. sq it.� PP
Other Distribution box (p(_) Dosing tank ( )
Percolation Test Results Performed by......�<?2.4:0..... /41 _ C.L: ..Zt�S... Date .... `^...-1_O_n- 5t
Test Pit No. I .... GZ..minutes per inch Depth of Test Pit ... ¢¢........ Depth to ground waterR.xT......>K7l)..^
Test Pit No. 2................minutes per inch Depth of Test Pit.................... Depth to ground water.C� :.tom.".. 6�'
Descriptionof Soil................ zr5=�s-.......... .................. -............. -.......... I ...................... .. •............... ........................
............................................ -....._............................................................I—....
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 TITL, S of the State Sanitary Code — The undersigned further agrees not to place the system in
operation until a Certificate of Compliance has beeniss by the board o alth.
Sign�edd..... - .. ...... .. . ....... -7 ..,1..�'
Application Approved By...: � .9r�...C.. "� ......................... ......---�...... t- Z..---
Date
Application Disapproved for the follo&ing reasons:
Permit No ...... Afz__ 3 CI ............ ...........
Date
> - c
Issued_ -------- 3 ...Gl................
Date
THE COMMONWEALTH OF MASSACHUSETTS
BOARD OF HEALTH
.............................. ......... ... .OF ..... ........................... ......... :...........................................
Trrfifirate of Tantplittnrle
THIS IS TO 'CERTIFY, That the,In&vidual 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.
DATE.
...... Inspector....: ......`......................................:............