HomeMy WebLinkAboutApp-Permit-ComplianceNo. ............... . .::... Fins ...... 3.0. ...........
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THE COMMONWEALTH OF MASSACHUSETTS
BOARD OF HEALTH
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, ppliratinn for Disposal Warks Tonstrudion Vrrmit
Application is hereby made for a Permit to Construct ( V) or 'Repair ( ) an Individual Sewage Disposal
System at:
Sig
•oration - Address Cit t %r r C� pL�n'i'EY' or Lot No.
.............fid �1. .....o —:.? e�-c
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/� Owner f
..............il:._ ><�% ./..,� J c!i�:_....� �.... (. ��+►°'i��'t✓t4 / 1. �}� Address '12MLug /J ................
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Installer Address
Type of Building Size Lot ...... _.__ 2.. c�E Sq. feet
Dwelling — No. of Bedrooms.....✓` ... .............................Expansion Attic ( ) Garbage Grinder ( )
Other — Type of Building _._. k::��4....._._.. No. of persons ............................ Showers (-) — Cafeteria ( )
Otherfixtures.............................................................. .......... ----------- -......
.. ......_...
Design Flow...................5 ................gallons per person per day. Total daily flow ............. ................gallons.
Septic Tank — Liquid ca.pacity.kd_Oc.gallons Length.... �i...... Width;.4 ........ Diameter ................ Depth. i.........
Disposal Trench — No ..................... Width .................... Total Length .................... Total leaching area--_-i-.1_.5-....sq. ft.
Seepage Pit No ...... _.... ........ Diameter ..... .......... Depth below inlet.. 4.......... Total leaching area ................. sq. ft.
Other Distribution box ( ) Dosing tank ( )
Percolation Test Results Performed by.......................................................................... Date ............................. _..........
Test Pit No. 1...4. z:_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 ........................
---•---•-------------------••-----•-......-•------...........-----.•__....--•---------......------...--•---...............--...-•-............._.............
Description of Soil ......... ...... '-V., -D .....
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Nature of Repairs or Alterations — Answer when applicable...............................................................................................
.......................................................................................... ............... .......•-----............. ..............r .....................................
Agreement: 1
The undersigned agrees to install the aforedescribed Individual Sewage DisposalSystemin accordance with
the provisions of AITIw 5 of the State Sanitary Code — The undersigned further agrees not to place the system in
operation until a Certificate of Compliance ha een ' ued by the b rd of health.
�-
V
Application Approved Byre .. ........:.. -J
Date
Application Disapproved for the following reasons:
I ... .. 7 Date
Permit No...4'._��..:.Q.���.-•------------•-••--------------- Issued.. ---•---- .._......,.---------- -------------
THE
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THE COMMONWEALTH OF MASSACHUSETTS ^ ^ T ®
11F r/ &;
SOARCO OF HEALTH
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hirr�tf�r�t#r .a�f fa�rtt�rhttxtrr
HIS CER Y, That the Individual Sewage Disposal S7stem constructed or Repaired
by.b-IPEF.�J„-u� X['!9VAI.t!�C2...............................................
Insta l
W �J� er
has been installed,,in accordance withthe provisions of T _T B 5 f The State Sanitar Co e m the"
PP I Construction- Per iv'o._ ...... ................. dated_ .....
�..
a llcatiorl for Dls �osal Worts -.
THE ISSUANCE OF THIS CERTIFICATE SHALL NOT)BE"`C�NSTRUED ASA U ANT 9 THAT THE
SYSTEMY�ILL;FUNCTION;;SATISFACTORY. ,�
Insp or..