HomeMy WebLinkAboutApp-Permit-ComplianceIle -
No............... ... ........
THE COMMONWEALTH OF MASSACHUSETTS
BOARD OF HEALTH
7±vw.nl.......... OF ....... -y4? o --------------------------------------------
Applira ton for 14sposal Works Tons rn.rtion Frruttt
Application is hereby made for a Permit to Construct ( ) or Repair ( Individual Sewage Disposal
System at:
............... a� ....... 9r l.� �:�,s.... c��l�_....±...... __...------------W ------ + - . _-. �_o--�__ E�9-'`:i A P � o
1 —Lo on - ddress ` - �f or Lot No. -
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.............. ..
Own r Address
- G1A+Q C .� ,.44!� - } t- • - - ------ ------------- R .aAr........ S...-----. Ln ..l!!!1.�±1k...............
Installer Address
Type of Building t Size Lot ............................ Sq. feet
Dwelling —No. of Bedrooms_._.. %5 ..............................Expansion Attic ( ) Garbage Grinder (P'V
Other — Type of Building ............................ No. of persons-_-__--__--___--__-__---.___ Showers ( ) — Cafeteria ( )
Otherfixtures ---------------------------------•-----•-----._........_.......--•---------------------.---------•------........------------------------.._......_...
Design Flow .......... SS_____________________gallons per person per day. Total daily flow .._. �_2S_D....__._............_._gallons.
Septic Tank 4- Liquid' (a, acity_ 60 -gallons ` Length ... 7......... Width ..._.._...... Diameter ................ Depth ................
Disposal Trench — No. 14)k .S Width.q,.............. Total Length ..s�C?_....... 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. 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 ........................
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Descriptionof Soil ..................................................................................
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Nature of Revairs or Alterations — Answer when
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Ae
Agreement:
The undersigned agrees to install the aforedescribed Individual Sewage Disposal System in accordance with
the provisions of TIT1Z- 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 ealth.
7-
Signed./..---•-- ..... ---- ------------------------- --- -- - .�._t_..
ll
oplicationApproved By -------- -----------------•-.......................................................... �- � -`..
ate
plication Disapproved for the f ollo ng reasons------------------------------------------------------------------.............................................
Permit No ..... _ Q. q..
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Date
THE COMMONWEALTH OF MASSACHUSETTS
BOARD OF HEALTH
.X .. N ........... OF ...... Y. A 9 W a,,,:L.\ .......................................
Trrtifirtt#r of Toutplittnrr
THIS IS TO CERTIFY, That the Individual Sewage Disposal System constructed ( ) or Repaired (yam
by --------------------------.A— S�.i X3!1?.._.. . ---.......................................................... ._.:..-------------•-------------------
` C Installer n
at ........................ ._....�'t!�J -_�... ��
Q` `.. 1'`` ------------- w'=_.__VG !?.................................
has been installed in accordance with the provisions of TITLE 5 of The State Sanity Codejas des ribe in the
application for Disposal Works Construction Permit No ----- `?:nZZ.9............ dated_...--.]. /..�_ -. T .............
THE ISSUANCE OF THIS CERTIFICATE SHALL NOT BE CONSTRUED AS A GUARANT E THAT THE
SYSTEM WILL PUNCfTION SATISFACTORY.
DATE _Inspector_. _._. ..... :.lM��..
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