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HomeMy WebLinkAboutApp-Permit-Compliance3 7 —284 THE COMMONWEALTH OF MASSACHUSETTS BOARD OF HEALTH "•..C.0/�ilQ......... OF..... ynR.M..0-U--rz1___________________________________________ C� � r fir iun for Uhivuua1 Work.0 C outitrartiou VtrMft Application is hereby made for a Permit to onstruet (>el or Repair ( ) an Individual Sewage Disposal � System at: 1 M M ©P/� -�OVT14 le/YJOU°71`f � ............... �.�,_. 4 4 ..' - ..._ Rip.. ..._._..... %� /�(% ADM -- Ad ss /�y p j �f j� /wJ.S't/)_...._.. .•.� f. � 1'_�E:at..•--------BM x ---- /-27• ------- _v or.._ .(.l �.-Ci -------------- t ... -.... - Owner Address KEN PINA ....................... F—i -----•------------------ Installer Address Size Lot_ Z © Pa . 2. _ ...... Sq. feet Type of Building ) Garbage Grinder ( ) UDwelling — No. of Bedrooms --------------------------------------___.__Expansion Attic Other — T e of Building No. of persons____________________________ Showers ( ) — Cafeteria ( ) PaOther fixtures -----------------------------•-------------------•------------------------------•----------------- d- W Design Flow ------------------------- ------------gallons per person per day. Total d� ily`flow_.____._.___.._________-____ gallons - W Septic Tank — Liquid capacity/.6-OO.gallons Length_=_�i____ Width4_:14---- Diameter. _______________ Depth �___g`.. x Disposal Trench — No_ ____________________ Widths _.___._� ___._____ Total Length ......... ------ __. Total leaching area .............. __ ___sq. ft. � Seepage Pit No_______ ............. Diameter__6__'�'1_____ Depth below inlet__�t•.............. Total leaching area. _�.__sq. ft. Z Other Distribution box (�) Dosing Tank ( S IeA% Date_ __ � �T__-_. [ 9 7# Percolation Test Re ults Performed b------=---5 x'"" f """""' ' Test Pit No. 1�_2,minutes per inch Depth of Test Pit___ _.7_.......... Depth to ground water_/d---! Test Pit No. 2 ................ minutes per inch Depth of Test Pit .................... Depth to ground water .....-::.:::_:.._...--- tr Description of U N!_��ut�1 c �_a!`yl1�1'v._l1- W-- -• --- ----- Nature of Repairs or Alterations — Answer when applica.ble_______________________________________________________________________________________________ U U Agreement: The undersigned agrees to install the aforedescribed Individual Sewage Dis osal System in accordance with the provisions of T IIN � 5 of the State Sanitary Code — e ndersigned tl: agrees not to place the system in operation until a Certificate of Compliance has been is by t and i It . Signed ...... -- --•-•-----•-•••-------• •------------••-••-•••---••-•• ff `�.._.__..._. Date Application Approved BY-•-------------- ----------•------------•-------------- " Date Application Disapproved for the following reasons____________________________________________________________ ----------------------------------------------- Date Issued-------------------------------•-------------•---------- PermitNo --------------------------------- ----------------------- Date THE COMMONWEALTH OF MASSACHUSETTS BOARD OF HEALTH .......................TOWN...... OF......... XiMOUTH .................................................. Tatifiratr of Toutphaurr THIS IS TO CERTIFY, That the Individual Sewage Disposal System constructed ) or Repaired ( ) by-��---PINA-------------------------------------------- --------------._....----------------------....__....._...----------._....-- Installer L_ i * . ...................................................................................... has been installed in accordance with the provisions of TITLE 5 of Th State Sanitary Code as described in the application for Disposal Works Construction Permit NO.. ._{--�'---•--------- a.ted----- 9-5-'Z_8-- ----------------------- d THE ISSUANCE OF THIS CERTIFICATE SH L [+IOT BE ONSTRUE®S l �a81R;ANi}/EEf,TBIAT THE SYSTEM WILL FUNTION SAT�1~A,CTORY. � 7 p`° Inspector ------------------------------------------------------------------------------------