HomeMy WebLinkAboutApp-Permit-ComplianceNo.ZLilli
THE COMMONWEALTH OF MASSACHUSETTS
BOARD OF HEALTH
To..v-tri...................OF...... .c �.! .o..c� i1------.._.......----------------.........------
Appliratilan for Biapviial Works Toustrnrtinn rrutit
Application is hereby made for a Permit to Construct ( or Repair ( ) an Individual Sewage Disposal
System at: f95_0
.. .... _ . .._..-• -- ----- - - - -....-
Location -Addressor Lot No.
---V-0'AIML...... ---------------------------------•-------- -- - ---.....-----------..._.................---.........
Owner Address
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Installer Address
Type of Building Size Lot._1_-5.4.1.`'--------- Sq. feet
Dwelling —No. of Bedrooms ............ 93 ---------------------------- Expansion Attic ( ) Garbage Grinder ( )
Other —Type of Building ............................ No. of persons_----__..._--__-_--_______ Showers ( ) — Cafeteria ( )
Otherfixtures .................................. I...................................................... .............................................................
Design Flow ......... /.1_0 .........................gallons per pep&&n er day. Total daily flow ..........33.0..............__.__...gallons.
Septic Tank —Liquid capacityJ466O.gallons Length_: -9_'4 �.__ Width... �- /Q-". Diameter---------------- Depth.-
Disposal Trench — No . .................... Width ----- .............. Total Length .................... Total leaching area. -_--------------,..sq. ft.
Seepage Pit No________ ___________ Diameter.-_..._.. .._.... Depth below inlet ...... Total leaching area.:��?_ht_' ft.
Other Distribution box (✓f Dosing tank
Percolation Test Results Performed by ....... jz.__�'AI► Q_Pr � 1C -$----P ................... Date .......`2_-Z.t _�_ 5....._...
Test Pit No. 1.4 .----..__..minutes per inch Depth of Test Pit ---- 161B.I---- Depth to ground water,M.. WATOX
Test Pit No. 2................minutes per inch Depth of Test Pit .................... Depth to ground water ........................
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Description of Soil----------- -------------- �� ^- �. TS? f --------------------------------------...----------------------------------
.......................................................... %L4 1'�.€.1�� 1�!...TQ 1I4.. - � 4---------------.........-----..--...--------------
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Nature of Repairs or Alterations — Answer when applicable .......................................... ........ .----- ....... .......
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Agreement :
The undersigned agrees to install the aforedescribed Individual Sewage Disposal System in accordance with
the provisions of TIT E 5 of the State Sanitary Code — The undersigned further agrees not to place the system in
operation until a Certificate of Compliance has been issue by the board of health.
:-�:.. ........................... ... ' .. /..:. , _....
Date
Application Approved B .............. ..------- ._ a.: ..........
Date
Application Disapproved for the following reasons: ..............................................................................................................
Permit No -A)) -----------------------------
ate
Issued .. . �.. �/...
Date
THE COMMONWEALTH OF MASSACHUSETTS
BOARD OF HEALTH
................OF.................................................
Ta ifirab of f9-ampfianrle
THIS IS TO CERTIFY, That the Individual Sewage Disposal System constructed (�) or Repaired ( )
-7"'- - AA
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__ l-� .=_`, ........
THE ISSUANCE OF THIS CERTIFICATE SHALL NOT BE CONSTRUED AS A GUARANTEE THAT THE
SYSTEM WILL FUNCTION SATISFACTORY.
°7
4........................................................
FA
Inspector '
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