HomeMy WebLinkAboutApp-Permit-ComplianceTHE COMMONWEALTH OF MASSACHUSETTS
BOARD OF HEALTH
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AppliratiOn for Uigpaasal Mirkii Tinuarurtum trrmit
Application is hereby made for a Permit to Construct (41 -) or Repair ( ) an Individual Sewage Disposal
System at
J
f --� v _ ..... - - -- Tom- -- ------------ -------- -_ ...._1.----------- --------------- l a o
Uon - Address
or Lot No. �r
.. --------- ---------------------------------------------------- ............. --
Oa�ner Address
pW--••----•-•--- Y - --------
Installer Address
.7 ---------------Sq. feet
Q Type of Building Size Lot_ -�
Garbage Grinder ( j
HDwelling — No. of Bedrooms --------------3 ................. .------ _Expansion Attic (
)
pa, Other — Type of Building ............................ No. of persons -_.__. _._-_.-__...__-____---
Showers ( ) — Cafeteria ( )
a Other fixtures ____________________________----------------------------------------------------------------------------
Design Flow ------------5 ----------------�- --------gallons per person per�day. Total dail
---------•---------------------
flow ....__._..��___��--—------------- gallons.
Septic Tank —Liquid* capacityl.`.'_�_gallons Length ---------------- Width.-- ---_-..
Diameter ________________ Depth.��l�.__..
xDisposal Trench —No - ------------------_. Width --_.......y-------- Total Length -------------------- Total leaching area -------------------- sq. ft.
Seepage Pit No ....... /.......... Diameter* ... Z_a.5-.... Depth below inlet-! Rt...._._. Total leachin area.... `6�/-_sq. tt.
z Other Distribution box ( Dosing tank
Test Results Performed by._.�.Q �_.. �.._ � z G_`��x
"`� •. Date/1��._����.___.
Percolation
Test Pit No. 1__.:'cL-minutes per inch Depth of Test Pit„l __._.._-
Depth to ground
li. Test Pit No. 2 ----------------minutes per inch Depth of Test Pit --------------------
__-_____---__-
Depth to ground water ------ .-----------------
--------- -.1
---- ---------- - ----------------------. __ - --------------------------
-
O Description of Soil % T :-�t"zs"�--�- c.�--�------------------------
U---•------------------------------------------------•... -•----------•----------------------
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W-----------------------------•-----------•-----•-•-------------------------- -----------------------------.....
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UNature of Repairs or Alterations — Answer when app'_icable-------------- ---------------------------------------------------------------------------------
Agreement
The undersigned agrees to install the aforedescribed Individual Sewage Disposal System in accordance with
the provisions of TITIE 5 of the State Sanitary Cod he undersigned further agrees not to place the system in
operation until a Certificate of Compliance has bee /Yssn th board of health.
Signe--------------------------------------------------- -
Application Approved By--- _ -------- - -- - --------
-- =f` --------------
Date
Application Disapproved for the following reasons--------------------------------------------------------------------------------------------------------------
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Date
PermitNo. -----.--------------------------------------6 _ Issuer------ `X--� �P` ---------------------
Date
THE COP�MOI 1`,'c .� Cr P i": aCHLSETTS
- r.
THI I TO CERTIFY, That the Individual Seg�11 St oited ( y,i2(paired
b3---------
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T_ r1.,<<-l;s-------- - --•-------
at----------- ------ 11&4---Z.��_. ---------------------•-----•------•------- - - -----
has been installed in accordance with the provisions of TI �' T - of State & nitary C, -)de. as described in the
application for Disposal Works Construction Permit \T o._�'�._L�---__.____.._... dateds'.-.d!..-� `-----------------------
THE ISSUAI:CE OF THIS CERTIFICATE S14ALL HOT BE CO"ISTPUED AS A GUAZAIdTEE THAT THE
SYSTEM t' -.'ILL FUUC E IOM SATISFACTO1;Y.
DATE-----------•----------------•-------------------------------------------------- Inspector-----------------------------------------------------------------------------`------