HomeMy WebLinkAboutApp-Permit-ComplianceLTH
SSACHUSETT
No. 77THE
FHAEALTH . FEE
X11" OF
Gr
Ai. phration fur umpa at Suutrm Tonstrnrtiun Prrmit
A plteation is hei made for a Permit to Install (") or Repair/Replace ( 1) an Individual Sewage Disposal System at:
��ii-ti^-�ft��,i_ �L{' ��>
l Iail<Addi �� orLot No.
(�J iI r inasF
/r_i Owen Addnne
D,,igner or In<I:,11" Addrel,
Type of Building Size Lot )UI 60C::� Sq. feet
Dwelling— No. of Bedrooms Expansion Attic ( ) Garbage Grinder ( )
Other —Type of Building No. of persons ( Showers ( ) — Cafeteria ( )
Other fixtures
Design Flow h°; gallons per person per day. Calculated daily flow ,( ;) gallons.
Septic Tank — Liquid capacity i`�C0gallons Length Width 5 X°' Diameter Depth
Disposal Trench — No. I Width A I` Total Length FT's I notal leaching area II i t4, sq. ft.
Seepage Pit No. Diameter Depth below inlet Total leaching area sq. ft.
Other Distribution box ( /) Dosif g tank ( ) '7
Percolation Test Results Performed byL 1 I"� —I, ril f7 t`It. � Date>' (7 C ( t
Test Pit No. I G- minutes per inch Depth of Test Pit )L{ c( 61 Depth to ground water V44
Test Pit No. 2 Z, nunutcs per inch Depth of Test Pit I �" Depth to ground water I r ° 4:,_
Description of Soil O` "ID rare/rn�<drG�R° _�L�" (.I Ntcrf >rrr4
Nature of Repairs or Alterations — Answer when applicable
Date Last Inspected
Agreement:—The undersigned agrees to install the aforedescribed Individual Sewage Disposal System in accordance with the
provisions of TITLE 5 of the State Environmental 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
Dale
-g'-2—e77
Data
Application Disapproved for the following reasons:
Permit No. T7— 7Z,
Issued
Dmc
THE COMMONWEALTH OF MASSACHUSETTS
�'sYJ, ✓'iy� BOARD OF HEALTH
Trrtifiratr of Tomphatirr
THIS IS TO CERTIFY, That the On -Site Sewage Disposal System instle�d (�,) or Repaired/Replaced (
for/,C, c�'`k'^.-;�Y",= 'r'" i!�'iZ.� at 7
has been constructed in accordance with the provisions of TITLE 5 of The Statetnvironmental Code as described in the
application for Disposal System Construction Permit No. —97—'?Z—dated ,;e _..1 e5 "7
Use of this system is conditioned on compliance with the provisions set forth below
THE ISSUANCE OF THIS CERTIFICATE SHALL NOT BE CONSTRUED AS A GUARANTEE THAT THE
SYSTEM WILL FUNCTION AS DESIGNED. This Certificate expires on
Dale
DATE . 27 Inspector L� " L '� "Z( >';'