HomeMy WebLinkAboutPermit 79-413 • No / Li t e%
Fss..I.p_P
THE COMMONWEALTH OF MASSACHUSETTS
BOARD OF HEALTH
OF
Appliratiun fur Diposal l lurku iIinu trurtiun tirrmit
Application is hereby made for a Permit to Construct ( ) or Repair ( an Individual Sewage Disposal
System at:
Sou73e S, to/Clr .072. _.... :.-.�..eitf.P- ..._..• ...........---.._,
P4,A.e tz_ �Yvr.S/� aTs,zi i'v.(4 fXy92 aA/ r .I.1.4.., e..9*
tk:..
Owner Address
a , CS. dt1 Cn. ..0 t. �Jl6�f GoGSTEtln) 242, 6 ...
InatalTer�s'a�'S #/l .ZAddress
Type of Building Sizeze Lot Sq.feet
.. Dwelling—No. of Bedrooms Expans�iop Attic ( ) Garbage Grinder ( )
aOther—Type of Building ..."4"dT �- No. of persong'X—'4‘. / Showers ( ) —Cafeteria ( )
d Other fixtures .gZ — - 2_ ,y7Za
Design Flow ..7`�..,5 gallons per person per day. Total daily flow.* 2.,_...f.:7-le-O gallons.
W
Z Septic Tank—Liquid capacity $gallons Lgngth Width Diameter Depth
x Disposal Trench—No-----7.-- Width./8 Total Length re"'' Total leaching areal..f!.X.r.O.sq.ft.
Seepage Pit No Diameter Depth below inlet Total leaching area_ sq.ft.
M Other Distribution box( ) Dosing tank( )
a Percolation Test Results Performed by Date
Test Pit No. 1 minutes per inch Depth of Test Pit Depth to ground water
Lr. Test Pit No.2 minutes per inch Depth of Test Pit. Depth to ground water
Pi
O Description of Soil
x
U
W
UNature of Repairs or Alterations—Answer when applicable..fte*:749 C 4F deXi S —,v C?
4. 11:‹r5!r..N.9- .ine Z ,1-1-,6 t A7Zcd-cf/c"a=7 A?z.0s^-1
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.
Signed..
Application Approved By 1 l Da"(�
Date
Application Disapproved for the following reasons•
Date
\ Permit No......._..........._.....______________ Issued._
Date
r
' NO
FEE
T THE COMMONWEALTH OF MASSACHUSETTS
BOARD OF HEALTH
OF
A1ptireiun fur 3i, puutti illthrk5 &m at-action Prrwit
Application is hereby made for a Permit to Construct ( ) or Repair ( an Individual Sewage Disposal
System at:
S"ca% i -Si'peJ/z(s Qr� ..� ie :�ri) c.rifl
Location-Address le, .- or Lot �o.
t"�.?.s4
Owner Address
41 l� s, 8 . Gso ,- C . ��C �.%Ze:..4.T G</ii..STpc/t- lam' /Y�!/c.� !.r-.4i
Installer 14 S7"57&Ass 4 / C Z Address
d Type of Building / Size Lot Sq. feet
U Dwelling—No. of Bedrooms Expansio Attic ( ) Garbage Grinder ( )
::14 Other—Type of Building _..Z.=f _7 L- No. of persons+ir"- '� / Showers ( ) — Cafeteria ( )
a, Other fixtures 2 s Z. /_ .
d -2: c. a
W Design Flow ... .-..5- 11ons per person per day. Total daily flow..,�..z.—,.___/7.1 . gallons.
W •t Septic Tank—Liquid capacity - enons Length Width Diameter Depth
Disposal Trench—No. Width.../ Total Length ,�� Total leaching area_ 11r-,, q. 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
,aa Test Pit No. 1 minutes per inch Depth of Test Pit Depth to ground water
(i, Test Pit Na. 2 minutes per inch Depth of Test Pit Depth to ground water
O Description of Soil
U
W _Nature of Repairs or Alterations—Answer when applicable .��c'9 e �-' ‘ $T--v c7
-. _.4-r .f!(- -v 1 ys: Q , 72 teL A777 c r/'a:47 "7C--'9"%1
Agreement:
The undersigned agrees to install the aforedescribed Individual Sewage Disposal System in accordance with
�'1'�•
the provisions of^l T_Lv 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.
Signed. .
,� �^ � Date
Application Approved By .t ._ _.-_) J tiL‘'7 #
Date
Application Disapproved for the following reasons:
Date
Permit No Issued_
Date
THE COMMONWEALTH OF MASSACHUSETTS
BOARD OF HEALTH
OF
&rtif irer of Qlontplianrr
THIS IS TO CERTIFY, That the Individual Sewage Disposal System constructed ( ) or Repaired ( )
by
Installer
at
has been installed in accordance with the provisions of TITLE 5 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 GUARANTE AT THE
SYSTEM WILL 7TION TISFACTORY.
DATE 7 Inspec -