HomeMy WebLinkAboutApp-Permit-ComplianceTHE COMMONWEALTH OF MASSACHUSETTS
CJJ J J BOARD OF HEALTH
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Appliration for Biipuial Works Tonotrurtion rrmi#
0 Application is hereby made for a Permit to Construct ( ) or Repair ( X) an Individual Sewage Disposal
iyvstem at:
Tbarkkex...Shoxa..Rd.... Yaxmmx thp=t-------------------•--
Location - Address
Q9r.aX.d..R.._1VkAu1if fe------------------------------------------•-•-----
Owner
.A.. &-- B-- Canc o..----•----•-•----------------•-------------------------------------
Installer
Type of Building
Dwelling — No. of Bedrooms
Other — Type of Building ---
Other fixtures
.....#142 ........................ CSO l — 8 1 YYl ! 10
or Lot No.
---.....lc V.L.C.tlex..Sharre... Rd.....................................
Address
-------•35..: Main St. --.. ................
Address
Size Lot ............................ Sq. feet
.................Expansion Attic ( ) Garbage Grinder ( )
No. of persons ............................ Showers ( ) — Cafeteria ( )
Design Flow............................................gallons per person per day. Total daily flow ............................................ gallons.
Septic Tank — Liquid capacity ............ gallons Length ................ Width ................ Diameter ---------------- Depth ................
Disposal Trench — No ..................... Width .................... Total Length .................... 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 Repairs or Alterations —Answer when applicable -100 } ga— ;}.ort.•stone... pack--- ove-rf-j;aw--------------
Agreement:
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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 Compliance has been issued by the board of health.
Sign_� `'----------------•- -----
Application Approved By------ - -- -----........ -------•-------------------••----------•--•--••----•-----•.--•-••-
�/ O . .. ...----
Date
Application Disapproved for e f oll ing re ons:-----•--------------------------••-•----------------.....--.....----------------•---.._..--••--------..........
.--------------------------------------------------------------------------------•-------. I--------------•-•-----------------------...---------------------•-----------------------
Date
Permit No.---- -------------------------- Issued _.... /�I&A
Date-•---------------•----------•
THE COMMONWEALTH OF MASSACHUSETTS
BOARD OF HEALTH
....................... Tcmwn........ OF ........ Y rm41.....................................................
f9rdif iratr of Iontplittnrr
THIS IS TO CERTIFY, That the Individual Sewage Disposal System constructed ( ) or Repaired ( x)
by --------•A- .$&MCQ....3SQ-.LD..61......Wo---Yarlimtb------------------------------------------•-•-........---........---•-..:_.._...._
Installer
at...............42 _z`'harft..Rd ...... Y.aXt= thpAxt-----------------------------------------
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 ............................. I...............:.:.
THE ISSUANCE OF THIS CERTIFICATE SHALL NOT BE CONSTRUED AS A GUARANTEE THAT THE
SYSTEM WILL FUNCTION SATISFACTORY.
DATE-•-•---------------------------------•---.....----...--•---.................... Inspector ...................................................................................