HomeMy WebLinkAboutApp-Permit-ComplianceA �
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THE COMMONWEALTH OF MASSACHUSETTS
BOAR® OF HEALTH
Apptira#iou for Dispaaal Works Tomitrnrttnn pamit
Application is hereby made for a Permit to Construct ()() or Repair ( ) an Individual Sewage Disposal
System at:
' E .
Location - Addrsrr 7 !CJ� Ai JY No. % n
..............4 .........................................) .............................................
GL� ry' �``
Owner Address
�
........... a Installer Address
d Type of Building Size Lot___ �� .-24-0
®.-_Sq. feet
U Dwelling — No. of Bedrooms ............. :_-__•-------------------------Expansion Attic ( ) Garbage Grinder ( )
Other — T e of Building No. of persons ............................ Showers ( ) — Cafeteria ( )
aOther fixtures .-----•---•-----------•-•--------•----•------•--•--- --•------•-------•-•------------------------•------•••----••-•---------------•----•-•-------•--
3 C3________._ -gallons.
W Design Flow ---------------------------6-...... gallons per person per day. Total daily flow .......... :•__.-_ gal es
WSeptic Tank — Liquid capacity j.(Z .gallons Length.i�__-6.. Width._-L_a.Diameter................ Depth -4.1--l".
x Disposal Trench — No . .................... Width l_...... .................... Total Length .................... Total leaching area -___---_-__--___--sq. ft.
Seepage Pit No -------- f------------ Diameter... ----- Depth below inlet --- Cs.• .............. Total leaching area.Z 0.._...sq. ft.
Z Other Distribution box (k) Dosing tank ( ) ��4 /
`-' Percolation Test Results Performed by.._.SQ�T�'��-_C nob ----• Date ........ .... .....f_. __�� ____..
a
Test Pit No. 1Z.JFJ_f:Lmmutes per inch Depth of Test Pit .... !.4._4'"__ Depth to ground water --- 1_44 ..........
�T4 Test Pit N,3. 2 ... _.......... ._minutes per inch Depth of Test Pit -------------------- Depth to ground water ........................
P4............................................... ---•-----------•••-•••----------••-----•-----•------.........................................................
O Descri tion of Soil _ !4{U' Fj ° {'YI t� (v ` x3d�------�-iv't..�_... ....
U--------_.�z-....4. '- r3 S > •---------------------------------------
w-------------------------------------------------•---•-----••---•••------•-----•------••----•----------•--•-•-- -----•----•--•----•--------•-------•-------•-------•--•---------•--••--------...-----
UNature of Repairs or Alterations — Answer when applicable.._________________•____.________.-..--________--___-_-_--:___•--._-_.-.__-.-----•_--•----_--__.
Agreement:
The undersigned agrees to install the aforedescribed Individual Sewage Disposal System in accordance with
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the provisions of : � --E, 5 or the State Sanitary Code —The undersigned further agrees not to place the system in
operation until a Certificate of Compliance has been iss d by the oard of hea .
Signed_.
---------•-----------------------------•--- •-
Application Approved By -•---Gr/ - .1
ate
Application Disapproved for the following reasons-----------------------•---------------------•----•------------•----------------•---------------------------••---
Date
PermitNo --------------------------------------------------------- Issued ------------------------------------.-----
Date
THE COMMONWEALTH OF MASSACHUSETTS
BOARD OF HEALTH
OF.....................................................................................
(gatifirat e of Tomptianim
THIS IS TO RTIFY, That the Individual Sewage Disposal System constructed (�_) or Repaired ( )
by ------------------ — --------------- -------- ---stiller ---------------------------/
• ,� 1 G1- ------------------------------------------
-------
--------------- - '---•--./------•------------= Tr � .,rdinte
has been installed in accordance with the provisions of TI TLE > of The State Sanitary Cord/e s de ribed in the
application for Disposal Works Construction Permit No .... ao-_"_' }�____-.._-. dated___._,/ l .-- --------------
THE ISSUANCE OF THIS CERTIFICATE SHALL NOT BE CO4S-T-R ED AS A G AR TEE THAT THE
SYSTEM WILL FUNC)nON SAT SFACTORY.
DATE... %------------------------ Inspector_ I.0
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