HomeMy WebLinkAboutApp-Permit-ComplianceTHE COMMONWEALTH OF MASSACHUSETTS
BOARD OF HEALTH
------.... OW..t4........... OF.....yR.k'M.0.0'?z`1.............................................
Applirution for Disposal Works Tonstrnrtiun ibrutit
Application is hereby made for a Permit to Con tr(a())or4epair ( ) an ndividual Sewag isposal
System at: o7.C,SE P A) P-1 61 $/ 7- KO 1LN
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Location -
Asd,dress
14-C ............ 4710x
wner
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Installer
Address
Address /
Type of Building � Size Lot.jJ.+ S4_ ......... Sq. feet
Dwelling —No. of Bedrooms............................................Expansion Attic ( ) Garbage Grinder ( )
Other — Type of Building ............................ No. of persons ............................ Showers ( ) — Cafeteria ( )
Otherfixtures------------------------------------------------------.-------•----------------------------...---------------.......------------------------........_.
Design Flow ------------------__------- per person per day. Total daily flow ........................ LT.P._._.. gallons.
Septic Tank —Liquid capacity/bOD..gallons Length.13..-G.`-' Width !_.1i2°! Diameter ................ Depthl.
�-. ..
Disposal Trench — No ..................... Width............. _...... Total Length .................... Total leaching area.._-----.._ ......... sq. ft.
Seepage Pit No ........ I .......... Diameter..G. .2._... Depth below inlet ... '¢-__......... Total leaching area�4_----sq. ft.
Other Distribution box ( Dosing tank J
Percolation Test Results Performed by.. W,EE7--�• ` -.`- 1-`--- '�.... Date... .1.?8....---...
Test Pit No. 1 L j5-.ff +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 ...... J ....... -�-�-LFfl.-) ..... F ME... . �C!L� _j----0-A/Aff/C.---..22.�f
....ix-1-"---..�'.L.Fx+ti`-----�'i��-----cf _��___�1•_a.�_.11. �1%�7...._..�-� '_..�� ��t_._�t/a__ �r1..�J'.�r�.._.._
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Nature of Repairs or Alterations — Answer when applicable..............................................................................
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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 'sue - th a4j health.
Application Approved
;z'.,!D
at
te
Application Disapproved for the following reasons--------------------------------------------------------- ------------------------------------------------
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Date
PermitNo ......................................................... Issued --------------------------------------------------------
Date
THE COMMONWEALTH OF MASSACHUSETTS
BOARD OF HEALTH
.......................................... OF .....................................................................................
(Intifira tr of Toutpliaurr
THIS IS TO RTIFY'hjt�he Individual Sewage Disposal System constructed (') or Repaired ( )
by.... -- ---------------------------------------------------------
'A
r ..._..
at------------------------- . . •-----............. --------------------------------------------------`.--------------------------------------------
has been installed in accordance with the provisions of T'C�n . pehe State Sanitary * dtsr&il/el ' the
application for Disposal Works Construction Permit No. ---_!------------------------ da.ted._....__.__.____...................�-------•
THE ISSUANCE OF THIS CERTIFICATE SHALL NOT BE CONSTRUED AS A GUARANTEE THAT THE
SYSTEM V9LL FUNCTION SATISFACTORY.
DATE .............. Z lu . 7. Inspector_....