HomeMy WebLinkAboutApp-Permit-ComplianceNo. �..............................
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THE COMMONWEALTH OF MASSACHUSETTS
BOARD O. HEALTH
/u.." • ....-- -- ..OF .................. ............................�----------------.......------------
App iration -fur �iiipagat or
- twtrurtinu Prrutit
Applica ion is h-er�eby`made for a Permit to Construct ( or Repair ( ) an Individual Sewage Disposal
System at : 5 1 �►an-4-m c- ice - 4— A �1z -
`-`--- --------------------------------------------------------------------------'`•1�---.-_'_J iR-P__. � -----------------
Location
�c . - Y4'i2
_ Address or Lot Ny.
Owner Address
a�.....................................
Installer Address
Type of Building Size Lot ---------------------------- Sq. feet
Dwelling —No. of Bedrooms ----- 3 .................................. Expansion Attic ( ) Garbage Grinder ( )
Other — Type of Building 44!______________ No. of persons____ - AF!________._________ Showers Cafeteria ( )
Q' Other fi=r d - - ---•------•---------•-_-----
WDesign Flow ................ __ ................. gallons per person per day. Total dail flow.______ _C.�.___.__________-__.___ga lons.
WSeptic T• ak-Liquid capacity(.4 .gallons Length__,St-G`_ Width ____�-�G,"Diameter ----- _____ Deptli__:-G_-.-
x Disposal — No- -•--•------•---- --- Width ------ 0i3........ Total Length_-- 3•--•----- Total leaching area -•---4A_ �....... sq. ft.
Seepage Pit No-____--_— ... Diameter____________________ Depth below inlet____________________ Total leaching area_________. ..... ._.sq. ft.
Z Other Distribution box (� Dosing tank )
'-' Percolation Test Results Performed by__________ ___t..._._T'>. ................ Date...'?-
aTest Pit No. 1&55 inutes per inch Depth of "fest pit ..... Depth to ground water ----
(i Test Pit No. 2 ................ minutes per inch Depth of Test Pit .................... Depth to ground water ------ •-----------------
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ODescription of Soil -------- d--` t-..---•- L Q. y Su? - . -----------------------•-_--•- ---------•---•-----------------•----------------------
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W -•----------------------------------- &A 402CJ---
VNature of Repairs or'Alterations — Answer when applicable ----------------- _-------------------------------- •-------------------------------- .________---.
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Agreement :
The undersigned agrees to
the provisions of Article NI of th
operation until a Certificate of Co
Application Approved By
install the aforedescribed Individual Sewage Disposal System in accordance with
e/StatSanitary Code — The undersigned turther agrees not to place the system in
e has been issued by the board of h lth.
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j D
Application Disapproved for the following reasons- ----------------------------------------------------------------------------------------------------------------
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Permit No.----•- �- 1 ------------------------------------------------------ -----•---•- Issued-
---Date ----
Date
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THS„ COMMONWEALTH OF, MASSACHUSETTS
BOARD OF HEALTH