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HomeMy WebLinkAboutApp-Permit-Compliancer?....' No.. . _ 82....313 Fps.. ,�.................. THE COMMONWEALTH OF MASSACHUSETTS BOAR® OF HEALTH Appliratinn for Disposal Works Toustrurtinnamit Application is hereby made for a Permit to Construct System at: ...... .... Location - Ad ress ..._... ....... Installer ( C- -ef Repair ( ) an Individual Sewage Disposal . ...... �'.ec...� -- c....-------MRE:: 1 b D F 10l or LotNo. Address .... .......... .... ................. Address 74, Type of Building Size Lot... '" ___ 3q. feet Dwelling —No. of Bedrooms_ ........ �...........................Expansion Attic ( ) Garbage Grinder ( ) Other -Type of Building ............................ No. of persons ............................ Showers ( ) — Cafeteria ( ) Otherfixtures------------------------------------------------------.-----------------------------------•----------------...•---•-----............---••-........---- Design Flow ............ ...................gallons per person per day. Total daily Aow.......�`�r_�_._.................. gallons. Septic Tank—Liquid capacitallons Length ......_. Width .... '�,�_..... Diameter ................ Depth --- Disposal Trench — No . .................... Width -------- ........... Total Length .................... Total leaching area --__---------------sq. ft. Seepage Pit No...__ ---------- Di eter.... /. ...... Depth below inlet..... ....-... Total leaching area -__3 . �-sq. ft. Other Distribution box ( Dosing t ) Percolation Test Results Performed by..-, .. %:'.)------------------- Date ...l�........ ��`� Test Pit No. 1 ....... inutes per in Depth of Test Pit..��` Depth to ground water .... . ------------ Test Pit No. 2---.'��triinutes per in h Depth of Test Pit../Y' Depth to ground water ------ . Descripti of Soil ✓ e ' /P rV . ..� 'l - Nature of Repairs or Alterations — Answer when applicable ------------------ /Y •----------------------------------------------------------•---------------.....------•-•-----------------------------------------•---------------•--•-----------------.............................. 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 Compliant s een issu by the health. Signed --• ............. -------•-z-.. /,� � Date Application Approved By. ----��=----- •- Date Application Disapproved for the following reasons--------------------------------------------------------•------------------------------------------------- --------------------•-------....--------.....------------------------------....--•----------------------------------------•--------------•--------------------------•--------------------------• Date Permit No._ 2__ -3 ?.a------------------•-------- Issued ......_ -----•----------- Date THE COMMONWEALTH OF MASSACHUSETTS BOARD OF HEALTH ...... ... r.......« ..........OF ....... ...... ......... r... . ........................... AT wrrftfirFatr of Toutplianrr THIS IS TO CERTIFY, That the Indiv ual Sewage Disposal System constructed ("-) or Repaired ( ) by ••- ---- .--- . ----•--•=-- .................. --• ---- -------------------------------•------------ /r t 1 . ...................... e_.___. . Install6r 3___ .._...... ._.. _._. _---- 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.___.;...2 /- i ----------- dated ___._ �.... r� .Z ................. THE ISSUANCE OF THIS CERTIFICATE SHALL NO STRU S A GUARANTEE AT THE SYSTEM WILL FUNCTION SATISFACTORY. DATE.... •�r`= = '�•. ----�-............................. InsP -•------------.......... . --- ----...... ................... -•------•--.