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HomeMy WebLinkAboutApp-Permit-ComplianceN. '3s-6 .� ....... Fps. lo THE COMMONWEALTH OF MASSACHUSETTS BOARD OF HEALTH ............................OF.......... C"/ .......................................................... Appliration for Disposal Works Tonstrudion Prrmit Application is hereby made for a Permit to Construct System at .......... ` .' ._....r_...tic---............................... ---..Lo ion - Address Installer Type of Building Dwelling —No. of Bedrooms. Other — Type of Building ---- Other fixtures .......... Design Flow --------------------------- ---. Septic Tank —Liquid* capacity Disposal Trench — No ............ . Seepage Pit No ..................... Other Distribution box ( ) Percolation Test Results 1 Test Pit No. 1 ...............m Test Pit No. 2 ................ ) or Repair Q an Individual Sewage Disposal L01- .. ©c o._.... - �-a..M.......................... r Lot No. �3 ............................................... dress ----------- -` . -�J ----------------------------------------------- Address Size Lot ............................ Sq. feet ..Expansion Attic ( ) Garbage Grinder ( ) No./ of persons ............................ Showers ( ) — Cafeteria ( ) {._..-g s per erson per day. Total daily flow............................................gallons. g ength ................ Width ................ Diameter ................ Depth .... -----....--- W' th................... Total Length .................... Total leaching area .................... sq. ft. nete .................... Depth below inlet .................... Total leaching area .................. sq. 'ft. Dosing to ( ) rfrmed by-------•--.............................................................. Date ........................................ tes per inch Depth of Test Pit .................... Depth to ground water ........................ ztes per inch Depth of Test Pit-------_---------- Depth to ground water ........................ Description of Soil .......................... ................ Nature of Repairs or Alteratio s.— nsw w -----------------------------------------------------------------------•--•........... ................................................. Ji.+c.....p.{....:... 1......... i!. ...... #...h. ........... ...................................................................................... Agreement: V The undersigned agrees to install the aforedescribed Individual Sewage Disposal System in accordance with the provisions of TITLZ 5 of the State Sanitary Code — The undersigned further agrees not to place the system in operation until a Certificate of Compliance has been issueddbb the bo of health. c / 31 Sig ed..�'� L= < -. ApplicationApproved By ........ ......•------------------------•....---•-•---•.......---......---•--....... D ' 1""' ate Application Disapproved for the f owing easons---------------••----•-----------•-......---------•----••-••---------•-------•-----------------••---•---•-----._ ..----------•-•--------•-•-•--•------•--------•-•------•-•------------------------------------------•-------•---•----. .... ------- ------- Permit No. �-6_1-------------------------------•------ Issued_ - J-- / ............ z.. THE COMMONWEALTH OF MASSACHUSETTS BOARD OF HEALTH .......................................... OF.-... ................. ....................................... �rrtifirtt..of T.untphaurr THIS IS TO CERTIFY, T In v'du Se < e Disposal System constructed ( ) or Repaired } - P - ---------------- ......_..._ by --------------------------------------------------------- v ._...... _ -� ,( Installer at. -------1---1-.7......-/ ---I-A4AJ-C ---- -- - _:V ------- - has been installed in accordance with the provisions of TITLE r of The State Sanita Y ode d - ii the application for Disposal Works Construction Permit No.. -&L !________________________ dated. ..__... _. .... _!_ .............. THE ISSUANCE OF THIS CERTIFICATE SHALL NOT BE CONSTRUED ASl ANTEE THAT THE SYSTE ILL UNCTION SATISFACTORY. ; Jq 1 6 ............. Inspector....................r = i ---...---................ DAT ls_�-------•--•----1