HomeMy WebLinkAboutApp-Permit-ComplianceNO.I,,.t.Z_'l Fss_... L S'
THE COMMONWEALTH OF MASSACHUSETTS
BOARD OF HEALTH
.........'.. !..f, 1.:N.ti.O......... OF.....�.C&.Y..UY\s:?s::.:?...............................................
Appliration for Bispaoal Works Cnonotrnrtion Frrmit
Application is hereby made for a Permit to Construct
System at:
-{'� Locatidn-Address
.............. .•_..vv .•.... L..d..)w'..ASIA`l.`.tt`... �c.$1.te..q .................
..............
Installer
) or Repair ( "-6i7 Individual Sewage Disposal
or Lot No.
....................i .. ny .... e ................................... ___.....
_ ..-.
Address
.............0 : .... :.w?.2 ::L:!! ........... bf -
Address
Type of Building/ Size Lot ............................ Sq. feet
Dwelling—No. of Bedrooms .....°.../ .................................Expansion Attic ( ) Garbage Grinder ( )
Other — Type of Building ............................ No. of persons............................ Showers ( ) — Cafeteria ( )
Otherfixtures.....................................................-............... ....................................................
Design Flow.. 110 ........................gallons per person per day. Total daily flow.....y �J...0........................gallons.
Septic Tank — Li uid capa�cityl150.gallons Length ..... il....... Width .... 6........ Diameter ................ Depth ................
Disposal Trench No... A..f !ti:&a Width ..... `efl_,...
-
Total Length ...�...6..`..... Total leaching area...................sq. ft.
Seepage Pit No ..................... Diameter.................:. Depth below inlet.................... Total leaching area .................. sq. ft.
Other Distribution box ( ) Dosing tank ( )
Percolation Test Results Performed by.......................................................................... Date ........................................
Test Pit No. I................minutes per inch Depth of Test Pit.................... Depth to ground water........................
Test Pit No. 2................minutes per inch Depth of Test Pit.................... Depth to ground water........................
Description of
Nature of Repairs or Alterations — Answer when applicable ...:K c ?nh'. ts....: .......
k?5........QSuYfe. !q&?.-..�..(.y1��.
Agreement. 1TovvY S'uvro°ka
The undersigned agrees to install the aforedescribed Individual Sewage Disposal System in accordance with J
the provisions of TITLr, 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 th board f--Iealt
Application Approved
Application Disapproved for the following
Permit No ........ Cr �.................. Issued ....,
.........................
` THE COMMONWEALTH OF MASSACHUSETTS
BOARD OF HEALTH
THIS IS TO
of Tompliattre
,;;,Date
Sewage Disposal System constructed ( ) or Repaired (
has been installed in accordance with the provisions of TIT 4f The State Sani1
application for Disposal Works Construction Permit No.......!..... ? .................... dat
THE ISSUANCE OF THIS CERTIFICATE SHALL NOT BE CONSTRUED AS
SYSTEM WILL FUNCTION SATISFACTORY.
DATE...................... fF.......................................... InsPectoF „-a
in the
THAT THE