Loading...
HomeMy WebLinkAboutApp-Permit-ComplianceNo.. .1..✓�zC.(�.� Fes$.. � ' ..�� THE COMMONWEALTH OF MASSACHUSETTS 'BOARD OF HEALTH oc-?-r oF...........1--rm.. va... ................ .. Applira#ion for Disposal Works Tonotrnrtion ramit Application is hereby made for a Permit to Construct ()} or Repair ( } an Individual Sewage Disposal System at: � t ::?...-f - ............. �� �° ................................................... .-.......ate -fit ..:-- qw a �- ocation - Add or LD 39 tom. v, �t (-rte----------------------- ---- ..�►%Ir�,+ ..,.�+J�...-. o►.r»uac� Owner Address ........... ... .L.4 -"W" ---------•-----------•-•---------------0-----•--------•---- ------------------•-------------•-••---•-••--------•-•------------•-•----•----•---•--------------- Installer Address Type of Building Size Lot -•_-----.jQ�©itq. feet Dwelling —No. of Bedrooms ...... 4 ................................. Expansion Attic ( ) Garbage Grinder ( ) Other — Type of Building ............................ No. of persons ............................ Showers ( ) — Cafeteria ( ) Otherfixtures---------•---•-••-------•------•..............................-.._...------------------------......•..........--------...........--------•--.......... Design Flow --------------------------------------------gallons per person per day. Total daily flow .............. 44b ................ gallons. Septic Tank — Liquid' capacitylggge.gallons Length ................ Width ................ Diameter ................ Depth ................ Disposal Trench — No ..................... Width .................... Total Length ............ ........ Total leaching area .................... sq. ft. Seepage Pit No..._..I.......... Diameter.._'�*.5_...... Depth below inlet ....... ±........ Total leaching area_;�I..sq. ft. Other Distribution box (X) Dosin tank ( ) Percolation Test Results Performed by..-_...�.A? n_.. 1243.4 m, .. _ lr+...................... Date ...... 'ILA -- -79--- 3 Test Pit No. 1.. Gtr..minutes per inch Depth of Test Pit ............... Depth to ground water -.__--__�?.±4!..... Test Pit No. 2................minutes per inch Depth of Test Pit .................... Depth to ground water ................ ........ --------------------------------------------------------- ------------------------------- Description of Soil.....0--_:3t�"•. o L.oa.vH___- a- t .---------------------------------------------------------------------------------------------------------------------------------------------------------------------------------•------• •-----......... .S," . i. ------------------------------------3. : s"4,....----------------------------------------- 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 TITiE 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 -•-•-----•- DApproved By---•- •••------•--. ... •-•--------..._•..............•--..... ---- ---_---'------- Dat Application Disapproved for the following reasons:----•-----------------------------------------------------------------------------------------------------•----• ----------------------------------------------- ------------------------------------------------------------------------------------------------------------------------------------------------ Date PermitNo ......................................................... Issued _....................................................... Date THE COMMONWEALTH OF MASSACHUSETTS BOARD OF HEALTH .......................................... OF .......... ............................................................. � rrufiratr of TompliFanrr THIS IS TO,CERT17, That the Individual Sewage Disposal System constructed ( ) or Repaired ( ) at.......... A ....... ......----•------ . t,4l has been installed in accordance with the provisions of TITLE > of The tate Sanitary Code de ribed in the application for Disposal Works Construction Permit No... ` -___. �1 dated_ THE ISSUANCE OF THIS CERTIFICATE SHALVNOT BE CONSTRUED AS A G RA TEE THAT THE SYSTEM WILL FUNCTION SATISFACTORY. DATE................................................................................ Inspector