HomeMy WebLinkAbout87-467 No.......................... Fits '
THE COMMONWEALTH OF MASSACH USETTS
BOARD OF HEALTH
OF Y/N 0.IL.1 r),,.i T-14-
Appliration for Disposal iliorks Tonstrurtion ilmitit
Application is hereby made for a Permit to Construct ( ) or Repair ( ) an Individual Sewage Disposal
System at:
..... -
Location 7 Address or Lot No.
---1).t..V1....412L. ... ., " 7- I 's....is.L....-1. t,.: ..
Owner Address ‘.,
\I -'- - , -k t\r I-,,-)f,:-/`7,"
4
Type of Building Installer Address
Size Lot Sq. feet
)(=i) Dwelling—No. of Bedrooms Expansion Attic ( ) Garbage Grinder ( )
C14 Other—Type of Building No. of persons Showers ( ) — Cafeteria ( )
..4 Other fixtures
Design Flow gallons per person per day. Total daily flow gallons.
Septic Tank—Liquid capacity gallons Length Width Diameter Depth
41
Z Disposal Trench—No. Width Total Length Total leaching area. sq. ft.
Seepage Pit No Diameter Depth below inlet Total leaching area_ sq. ft.
z Other Distribution box ( ) Dosing tank ( )
Percolation Test Results Performed by Date
•-.1
1-1 Test Pit No. 1 minutes per inch Depth of Test Pit Depth to ground water
1..1
gz4 Test Pit No. 2 minutes per inch Depth of Test Pit Depth to ground water
C4
0 Description of Soil
W
U
W
U 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 TITLE 5 of the State Sanitary Code—The undersigned further agrees not to place the system in
operation until a Certificate of Compliance 4as been issued by the board of health.
Sitd
.7,
Application Approved By 4:-, ___•
Date
Application Disapproved for the following reasons:
11
, 1 ":"? 13ate
719/
Permit—NI o L.' ...L 7 issued.??G'e oe -t4J /,./(2 (
Date
THE COMMONWEALTH OF MASSACHUSETTS
BOARD OF HEALTH
. ,
OF0.-
Trrtifiratt of Toinplianrt
,71-RA I... TO CERTIFY, That the Individual Sewage Disposal System constructed ( ) or Repaired ( ., )
by_42L-1
/2 Installer
at-.3.3..Yet.\1.72.0e A) ft c Al 11...:Cx 'A 1212.- ../.A.lic .T.CILTII
has been installed in accordance with the provisions of TgLE i5 of The State Sanitary Code as, the
application for Disposal Works Construction Permit No... ./.-61k7 dated. QC4A0te' cif/6.i..
THE ISSUANCE OF THIS CERTIFICATE SHALL NOT BE CONSTRUED AS A GUARANTEE THAT THE
SYSTEM WILL FUNCTION SATISFACTORY.
TIL A Pr1G"
4�
No V.--9.4. ..... F...../.5-
ss__/y:..:.........._.
THE COMMONWEALTH OF MASSACHUSETTS
BOARD OF HEALTH
lei ,Q o F P(ZlALA.L.T`l,-
.k1ptiratinn fur laispnnttt 'fl nrks Cltnnutrnrtinn f rrutit
Application is hereby made for a Permit to Construct ( ) or Repair (` ) an Individual Sewage Disposal
System at:
Location,-,. duress I . or Lot
Owner
Address
.
aAi4.Q 13 „ -, Ga l(V (1, Vo
Installer Address
Q7i Type of Building Size Lot Sq. feet
aDwelling—No. of Bedrooms Expansion Attic ( ) Garbage Grinder ( )
a,t Other—Type of Building No. of persons Showers ( ) — Cafeteria ( )
a, Other fixtures
Design Flow gallons per person per day. Total daily flow gallons.
W Septic Tank—Liquid capacity gallons Length Width Diameter Depth
x Disposal Trench—No. Width Total Length Total leaching area_ sq. ft.
Seepage Pit No Diameter Depth below inlet Total leaching area_ sq. ft.
z Other Distribution box ( ) Dosing tank ( )
"' Percolation Test Results Performed by Date
Test Pit No. 1 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
a
0 Description of Soil
W
UNature of Repairs or Alterations—Answer when applicable.as.i??v;l �� l ae Atr icy,:: (3.M.•.S;:.t-'I(t- \--t‘ --'x
., 1'po1 k__}L.k:t\' lk y)11... i-;,1 c'':— ,c,: ni_ ,L`c .2.1.i._t_a.A.:_.l
Agreement:
The undersigned agrees to install the aforedescribed Individual S�_ age Disposal System in accordance with
the provisions of TITLE 5 of the State Sanitary Code— The undetignedfurther agrees not to place the system in
operation until a Certificate of Compliance has nisssued) the and of health. /
g.
D to
Application Approved By i. 1_,�/AI
s:
ate
Application Disapproved for the following reasons:
Permit No r' _L IssuecL 69- =le4)'�.rid.(.
Date