HomeMy WebLinkAboutApp-Permit-ComplianceNo. 8731 Fes$_. DC7
THE COMMONWEALTH OF MASSACHUSETTS
BOARD OF HEALTH
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Applirtttion for Disposal Works Tons rur , ' n lrxutit
Application is hereby made for a Permit to Construct ( ) or Repair (L4 an Individual Sewage Disposal
System at: _
ddre or Lot No.
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wner�`��, . Addr
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Installer Address
Type of Building Size Lot..---_.._._.•-. ------------- Sq. feet
U
Dwelling —No. of Bedrooms --------------------------------------------Expansion Attic ( ) Garbage Grinder ( )
p, Other — Type of Building ............................ No. of persons ............................ Showers ( ) — Cafeteria ( )
a+ Other fixtures
Design Flow............................................gallons per person per day. Total daily flow ............................................ gallons.
Septic Tank — Liquid' ca.pacity_._._....._.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. I................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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Description of Soil................C11�r�l F....i4.i.l.-------.....---.--
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.------------------•-•-----------•--•------•-----------------------:....------------•---•-•----------------.......-•---------•-----------•---------------..--.......-----------•--- ------------•--------
"I.1. v r
Nature of R airs or Alterations — Answer w n a ICable._._.._._...G?�— .. __�?.!�!._._..�....... �. lam.. S
Agreement: v
The undersigned agrees to install the aforedescribed Individual Sewage Disposal System in accordance with
the provisions of
'ITIE 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 b the board of health.
Si d.
ate
Application Approved B -•--•--•---......--•-•--•••-••-••--•---•---•-•..................... .._..G� . � �--7-.......
PP PP Y---••--- - - - - •- - D e
Application Disapproved for the f oll 'ng reasons:--•----•--------------------------------------•--•-•---•------•-------...........-------•---•-•---........_.._
Date
Permit No. :5 7:. 36 g --- ----------------------------
THE COMMONWEALTH OF MASSACHUSETTS
BOARD OF HEALTH
........... OF ............./p/e�!!o...................................
(ffrrtifirtt of (l%utplinurr
THIS IS TO CERTIFY, That the Individual Sewage Disposal System constructed ( ) or Repaired (L11/
by..............----•-... = l !!ki .....�. - -- --- - - ... - ---..........- -- ............
��-- --- -Installer
has been installed in accordance with the provisions /of T F f The State Sanitar d scry ,�'n the
application for Disposal Works Construction Permit No.3------------------ date��n��� ��/ 1 //_
THE ISSUANCE OF THIS CERTIFICATE SHALL NOT BE CONSTRUED AS A GUARANTEE THAT THE
SYSTEMA WILL FUNCTION SATISFACTORY.
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