HomeMy WebLinkAboutApp-Permit-ComplianceTHE COMMONWEALTH OF MASSACHUSETTS
)BOARD OF HEALTH
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Apel ration for Dispolla Work.5 Tonstrudion 11rrmt#
Application is hereby made for a Permit to Construct ( YJ or Repair ( ) an Individual Sewage Disposal
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System atI/... - -- .. ...._.. -- ...........................
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Loca ion - Addres (— or Lot No.
.................1 ...Jgaz".1jn rJ--•-•---...................--•----�--✓ ......-'-, c'' -DrZ:- A=n c..zctr�vr2r
Owner Address
W
pq Installer Address 146-7
6 Type of Building Size Lot ............................ Sq. feet
U Dwelling —No. of Bedrooms ............................................Expansion Attic ( ) Garbage Grinder ( )
44 Other — T e of Building No. of persons ............................ Showers — Cafeteria
04 Other fixtures .....................................
Design Flow ................ I1.Q-................... gallons per pw"n per day. Total day flow ............................CD .................gallons.
is t r ,rte 1 �c
Septic Tank — Liquid capacity -1.000. -gallons Length-_ B..(Q."_ Width:__�.(Q.-.. Diameter ................ Dep th-`-�----.a _..
W Disposal Trench — No ..................... Width .................... Total Length ..................... Total leaching area .................... sq. ft.
x
3 Seepage Pit No ...... .,........... Diameter...... LQ....... Depth below inlet....... .......... Total leaching area_ :k.sq. ft.
Z Other Distribution box ()o Dosing tank ( )
`" Percolation Test R sults Performed by .... 7A.DUY) -.5- :.. ................ Date.l P'87. Z� l @f
' Test Pit No.
a YiY�tr, minutes per inch Depth of Test Pit._..__. _�� __ Depth to water....... �. �.._...
Test Pit No. ..%-2--. minutes per inch Depth of Test Pit ...1&25...... Depth top�t4--water...... L(a7.........
P4....-----••-••--•-- . - ...._..
O . Description of Soil.... o : W.
su8...24"-b"o�t�Cr, 5KN0 (06�`.77.�p�ctsE Fr-xao.� .._.
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?Z.........................Fc_ .(7A".Gc�ita! Sum / Zo Frc[.`_.._. �... 6.
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U I<(at e of Rspairs or Alterations — saver w en licable...........................................................................
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Agreement • `J
The undersigned agrees to install the aforedescribed Individual Sewage Disposal System in accordance with
the provisions of 'JI TL 5 of the State Sanitary o e — The undersigned further agrees not to place the system in
operation until a Certificate of Compliance has 1 Sanitary
the,bo4rd ojiealth.
Date
Application Approved By.___ a nZZ�
Date
Application Disapproved for the following reasons: ............................................................................................................
o Date .. --
PermitNo ......................................................... Issued.. ....--•-- ? ..2 .......
THE COMMONWEALTH OF .MASSACHUSETTS_
J BOARD OF HEALTH
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............ .... O F:.... ... .............
(Intifiratr of Taamulinnrr
T TO CERT FY, Th t he, Individual Sewage Disposal System constructed or Repaired
by • - "CLa -.
•--
L Instal
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at ..---•--. :..
has been insta led in accordance with the provisions of T11 F 5 e,� State Sanitary Cnde s descr b m the
application for Disposal Works Construction Permit No. � "' --0 -------_'- dated___...�......
TI4E ISSUANCE' OF THI CER IFICATE SHALL NDS-., STRUED A ANTES THAT THE
SYSTEM. WI�:I,FUNCTI N ATI5F TQRY.
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DATE.:.. ... Inspector_ ...........................................