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HomeMy WebLinkAboutApp-Permit-Compliance f �' _� .� , 'c._. � , � � � �� � � � .:��- . � ,,., N -� - Fss..J..S..?.:........-, � `' ' ;, THE CONiMONWEALTH OF MASSACHUSETTS ' BOARD OF` HEALTH �; . - -------�---1 D.�tit-----....oF.....�.R..�►'.Ar��.u..T..,N------------------------------�------------ � ,��t��tPFI�tTtli �.qx �t��.Q��t� �IIx�� �it�t,��1t.C�tlYtt P�lltt# I � � ; Application is hereby made for a Permit to Construct (k) or Repair ( ) an Individual Sewage Disposal � System at: , � ' L oT !2 �T ----------------_____.....�.._.............---.�1�1.+�.�1�l.-�-�--....Q�!��:--------.. ._._R_...R__�!is�.cfT:rl rnAp -lt4 L cation- dress t o. -�----------------"'•'--.... _. ----------------�,[.sa�.�pt:�.._.._.�'�.Q�.�'���.---...�:,�' ,�'�51.�.t�.--�'-�---�...�!����r�7---��:..����o Address � W ! a ----------------�:� °�.�.�..�.�:1`J �'� --- ------- ----------- --- ----. .....---- ----------------.._...-------------------------------------------------------o---- '. � Iastaller ��� � U T e of Buildin Address YP g � Size Lot_���_�,Z___.___._Sq. feet � Dwelling—No. of Bedrooms____________________________________________Expansion Attic ( ) Garbage Grinder ( ) aa Other—T e of Buildin YP g -------------•------•------. No. of persons------••-•----------•-----•- Showers ( ) — Cafeteria. ( ) � Other fixtures -----------•------------•---•-------•-••----------------------------------------------------•------------•---•--------•---•-----•-...---.........---- W Design Flow___________________________��...._gallons per person per day. Tota1 daily flow__._._._____._......__c��. _�?.._.___gallons. � W Septic Tank—Liquid capacit}��fl(,?.gallons Length$.�--�`'_ Width.�=_/.Q`�. Diameter________________ Depth��-�!!. x Disposal Trench—No. .................... Width_.__..._.__.._._____ Total Length....___.__._._...__. Tota1 leaching area,_._._________ sq. ft. 1 � Seepage Pit No.___._{_____________ Diameter._G__�:_I.�.__ Depth Uelow inlet.__. ;.�_.._.___. Total lea.chingarea._�.�:_�_...sq. ft. ; z Other Distribution box (� Dosing ta�lc O / Q I a Percolation Test Results Performed by_______��.I!S�E�,S.'�R._.�.___k����� Date__/'f..U._�::../__,�7L�.__.� � � Test Pit No. 1�,P.,Z„�ilinutes per inch Depth of Test Pit._�.5�'.`��._ Depth to ground water_.�a__1�,,G4TFC G4 Test Pit No. 2________________minutes per inch Depth of Test Pit______.__.._______.. Depth to ground water_..__..._..____.__.____. � ---------------J-----------------•---•-----------••------...--•-----••------.........---------......_..__...------------- - � Descri tion of Soil----�-L.��:h�...._.�E.�_�4t_�!.1�---..�"`�4!�1lrJ-----�h�q��---..(,�__C�--`_---�d�-�---�/t�C!_ x � c.� ------._ ..1�,$�.51?.s/L---------------------•----------•-----••-------.....--------------------...----------------------•-----------------------•----......-------....------•--...__...---•----- � -------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------- ' V Nature of Repairs or A�terations—Answer when applicable_______________________________________________________________________________________________ ----------------------------•----......------•-------------•-----•-•----...------------••---•---.....--------...---------------------------•-------------------•----•--•-----•-------....----------•---� Agreement: The undersigned agrees to install the aforedescribed Individual Sewage Disposal System in accordance with the provisions of iIT�..� 5 of the State Sanitary Code—The undersigned furtl:er agrees not to place the system in operation until a Certifica.te of Compliance has been issued by the board of health. Signed-•--•------••---•-•-•-------------------••-•----------....__.....__.....--•-------•--- ------•-•------•-•--......_..._ � /n Date � Application Approved BY----••-----•----•-------•- �G�._!--- ----- ----------- ------------- �.�."':-��."'..,�� � Date Application Disapproved f or the f ollowing reasons:-----•----------------------•---•-----------------------------•---------------------------------------•----•--- � ----------------------•--------•-----••-------------...----•-------._....----...--•------...--------•-----------------------------------------------------------------------......._. Date PermitNo-------------------------------------------------------- Issued.-------------•---------------.._._..------•------------ Date _ _ __ _— __ _— _ - - THE COMMONWEAI.TH OF MASSACHUSETI"S � BOARD OF HEALTH ( ... ..........�,Q.�'.�Ij✓•.�OF......�./.�.�.;,,,'.............................................. � (�rr�tf��rtt�e nf t�.u�t�rli�nrr THI IS TO CERTI�F ', That the Individual Sewage Disposal S�stem constructed �or Repaired O by.._......��.�..-_.._.._.�.�-.�G�?f�.�.�---------------------- ---------------- --....._.....----- •---- --- •--- -•--- - -•------------------ .�` Installer ....----•--------------- at..------,�.aJ..-------1�---------�--- -- -- --- - - ------ ------------------------------ ---- ----•-- •------•---- •--------------- has been installed in accordance with the provisions of TI�'LW j o tate Sani Code s described in the application for DisPosal VVorks Construction Permit i�'o.__._ _.�� __� dated___��_:__��._--�� � ------ � -•------ THE ISSUANCE OF THIS CERTIFICATE SI�ALL t+lOT BE CONSTRUED AS A GUARANTEE THAT THE S1(STEI�I WILL FUNCTION SATISFACTORY. 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