HomeMy WebLinkAboutApp-Permit-ComplianceN0.0 .----....... Fzs.............:
THE COMMONWEALTH OF MASSACHUSETTS
�-. BOARD 9F HEALTH
%sC.e�R� .............OF......
Appliration for Di-sposal Works Tonstrurtion jrrnii#
Application is hereby made for a Permit to Construct (),� or Repair ( ) an Individual Sewage Disposal
,Qystem at:
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cation - ddress ' 1 �(
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W Owner
-------•------•.................................................... •--•--.........................
Installer Address
Type of Buildig, Size Lot_... t2)9q. feet
Dwelling — No. of Bedrooms............................................Expansion Attic ( ) Garbage Grinder
a Other — T e of Buildiu
a
Other—Type g -------------------------- - No. of persons ............................ Showers ( ) Cafeteria ( )
d Other fixtures . ._
W Design Flow ----------------_--- ........... gallons per person dgy. Total daily flow c�� -------------------- gallons.
WSeptic Tank — Liquid' capacity.4 -.gallons Length.7'.6.... Width..., Diameter ................ Depth ---g._.: .
x Disposal Trench — No ...............:..... Width.................... Total Length -------------------- Total leaching area .................... sq. ft.
Seepage Pit No- _.._ /--..... D' _ meter......._�� ..... Depth below inlet ...... 6 ........ Total leaching area --- ZjC=..sq. ft.
ZOther Distribution box ( Dosing tank
Percolation Test Rests Performed b ...► x �. e ►.� C 2
Y I--- ;r ::.... Date --------------------------------
Test Pit No. 1._.... 2.._.minutes per inch Depth of Test Pit.....-- . c.b-.-- Depth to ground water...... .........
0-4
rX4 Test Pit No. 2 ----------------minutes per inch Depth of Test Pit ...... �L_g... Depth to ground water ...._ `c. .......
of Soil ......... _-
/L 3-5- -• S.
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Nature of Repairs or Alterations — Answer when applicable ................................................................
..------•--•-------------------------•--•-------......---------------------...------..........-•------......----•--•---------------------.......-------••------------------•...-----....•--•-------.....
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 be9A issued by the board of It
Signed... ------------`.t---- •------•----....--
aep
Application Approved BY Z. 1
Date
Application Disapproved for the following reasons:-------•------•--•-----•---•----•-------------------•-----------------------•-•-------...---...-------••--------
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Date
Permit No.----- == l =..5 ----------------------------- Issued ........-. l nz- .__.....---te ---
THE COMMONWEALTH OF MASSACHUSETTS
BOARD OF HEALTH
.......................................!..OF.......,r'...............................................
Tntifirati of Toutph tnrr
THIS. IS TO CERTIFY, That the Individual Sewage Disposal S7stem constructed ( ) or Repaired ( )
by'! ............................... ..------.......--------•------ .-----------•---------------•--......---------•-------------•-----•------.......------•----
Installer
at..............................
---------- -------
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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 -_ _......11............... dated .............. .__.................................
THE ISSUANCE OF THIS CERTIFICATE SHALL NOT BE CONSTRUED AS A� GUARANTEE THAT THE
SYSTEM WILL FUNCTION SATISFACTORY. <
DATE..:'....... ...................................................... Inspector._.._.; .... - ..........: