HomeMy WebLinkAboutApp-Permit-ComplianceTHE COMMONWEALTH OF MASSACHUSETTS
BOARD OF HEALTH
Aliptiratiou for Utinivovml lUvrkii Timitrurtiou Urruti#
Application is hereby made for a Permit to Construct yK or Repair { ) an Individual Sewage Disposal
System at:
------------- �..� �.,,, o Lot N
a! "AL --------
....
Wa .
Addres
Owner s
------------------------•----------------
.__�Installer Address
�4 Size Lot ---------------------------Sq. feet
Tvpe of Building Garbage Grinder
U Dwelling — No. of Bedrooms ......... __dam_' -_------•-____-_•__.---_-_.___Expansion Attic ( ) g ( )
Other — TyTe of Building ---------------------------- No. of persons_--_._-_-._-_-_-.---_--._-. Showers ( ) —Cafeteria ( )
WOther fixtures----•----•--------------------•-------•-----------------------------------------------------•---•------•------------•-•--------.._...-----------------
d
W Design Flow ----------- ---��------------------------- gallons per person per day. Total daily flow ------------- -`��------•-�---------------- ;ions.
-- Depth__- ._
- gt - � �- !---. Diameter-•------- - -- ---•---
WSeptic Tank —Liquid capacrtyl�_Q_C'?gallons Len h._� _-.__ . �'� kith-___-_
x
Disposal Trench —No - ------ ------------ Width ........ ............ Total Length .................... Total leaching area --------------__----Sq. ft.
� Seepage Pit No------- Z ........... Diameter._./__ d �_�_�_ Depth below inlet__.__:6..._..... Total leaching area_�.--sq--ft.6
Z Other Distribution box ('DQ Dosing tank ( }
Percolation Test Results Performed bye-.J----d-----�•. ----- j Date._
Test Pit No. --- minutes per inch Depth of Test Pit.._1_�4_". Depth to ground waterA=;�-!__._E7!-)
a Test Pit No. Z ................ minutes per inch Depth of Test Pit__._--_-.____---_-_. Depth to ground water-'_
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U'
aturc of Repairs or Alterations — Answer when applicable -----------------------------------------------------------------------------------------------
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Agreement :
The undersigned agrees to install the aforedescribed Se«age Djlsposa'l System in accordance with
the provisions of =ITEC 5 of the State Sanitary Code — The un I i T ed further' agrees not to place the system in
opera ' nail a,Certificate of Compiiance has been..s. d by tl •
z i Si -ileo _.. ------- --------- i lolev_----
Applicazlon Approved By---- --- -......... ----• ....---••---•-•------......................................-
Date
.-
........._-_...-._.___.
.. ----•••----------------
I11spproor 1 .
ved ,„ae ottuze:�:g re¢sons:__.•----•- ............
-------------- ..--------•----...---•--'-•------------ Date
1S -------------------------- Issued -----------•f- �- ? --�
Permit No ___________________ Date
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J - oacz de_ crlbed
i.._ Ic_:1.'-...`CE OF i".115 CE; Tli-l:l-'i.- ::~_r.L!, I:Q! 1� G� `: �D �S �. Gila',": E tEE iF.w7 i":..
D� Inspector �- — I,,-"=— ---------•-----