HomeMy WebLinkAboutApp-Permit-ComplianceTHE COMMONWEALTH OF MASSACHUSETTS
BOARD OF HEALTH
................. ......... OF,.yA."ahTW
... ...................................................................................
Appliration for Uispaaal Worko (foustrurtion Prrmit
Application is hereby made for a Permit to Construct or Repair (*) an Individual Sewage Disposal
System at: S9 �7
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................ . ............................... ........... ..... .................................. I .......... .................
0 Location -Address or. Lot No
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............ - -- ---- ......
0 LOY4 Ca Twner 2� t ,,,.Ajd4r:.s,
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.................................................. U. ..... ..... ..........................................
1.4Installer Address
Type of Building Size Lot ............................ Sq. feet
U Dwelling — No. of Bedrooms ............................................ Expansion Attic Garbage Grinder ( )
'_l
PL, Other—Type of Building ............................ No. of persons ........ _ ---_----------- Showers Cafeteria ( )
04 Other fixtures .................................................................... .................................................................. : ..............
Design Flow ............................................gallons per person per day. Total daily flow ............................................ gallons.
1:4 Septic Tank — Liquid' capacity ............ gallons Length ................ Width.........._..... Diameter-___________--_- Depth..._..._........
Disposal Trench — No ..................... Width .................... Total Length._.....--._...._.__. Total leaching area .................... sq. ft.
Seepage Pit No_____________________ Diameter.__...__.___.__..... Depth below inlet.........._._..._._. Total leaching area .................. sq. ft.
Z Other Distribution box ( ) Dosing tank ( )
Percolation Test Results Performed by ........................................................... .............. Date ........................................
aTest Pit No. I ................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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0 Description of Soil ........................................................................... I --- e - - - i! 0), --- ------ -- --------------
W s -----------------
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en applicable__-!- t��%.
U Nature of epair or Alterations — Answer w .....
.�-AAJ — ----- L omp .................................
P Wmv ,?,, '9Tmc-
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Agreement:
The undersigned agrees to install theafo ed Individual S des a e Disposal �S�e t6m in accordance with
aforedes
the provisions of TITLE 5 of the State Sanitary Co The undersi e urther agre not to place the system in
operation until a Certificate of Compliance has been i sued by thr boa of le
Si....... ............ ......... .................. ................ ----- ---- - ... ........ ......
Application Approved By ...... I .... ..... ...... ..... . ... .. ....... ......................... ......... ... - ----------
"/Date
Application Disapproved for the following ns: .... .........................................................................................................
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Permit No ...... ------------------------- Issued ....... Y, - /.�� ?/ ------ Dat ........
Date
THE COMMONWEALTH OF MASSACHUSETTS
BOARD OF HEALTH
............. J� .......... OF .......... �AC4 . ............................................................
...................
Tntifirav of Tompliatta
THtV IST CER-TIFY, T�at,t4e Individual Sewage Disposal System constructed or Repaired
by... ....... rn . ........ . ...... ................ ........................... -------------------------------------------- " ----------------
144er
07 0 )ZX
at.......... � - S'r i (.. It. e- ---- --- u."t.) -------------------
- . . ................ . ............................... -------- TZ -2 --------------------------------------
has been installed in accordance with the provisions of TITLE 5 of The State Sanitary Cod j as escribed in the
application for Disposal Works Construction Permit No... ---------_------ dated.- ..................
THE ISSUANCE OF THIS CERTIFICATE SHALL NOT BE CONSTRUE =ZRAN E THAT THE
SYSTEM WILL I FUNCTION SATISFACTORY.
DATE .------• ............................................ Inspector- r ....
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