HomeMy WebLinkAboutApp-Permit-Compliance��No.. ..
&PEI,IC-0 ' Y7 d9A/J' THE COMMONWEALTH OF MASSACHUSETTS
Q� I d ® BOARD OF HEALTH
.... .OF...il'_•----- ••.........••---
Appliration for Dispoiia1 Workii Tonarurtion rjernfit
Application is hereby made for a Permit to Construct () or Repair ( ) an Individual Sewage Disposal
System at Rb YA
.1% 1 L- . s ALpeation.- TddFesw MV0. 4P%&'0% —mw. or Lot No.
Address
Installer Address
Type of Building Size ----- Sq. feet
Dwelling —No. of Bedrooms________ .................................... Expansion Attic (Pq Garbage Grinder (0p)
Other — Type of Building ............................ No. of persons ............................ Showers ( ) — Cafeteria ( )
Otherj3qures ..--------•------••---•-•-•---•---•-•-••-••••--••---•-------•-•--•------••-•-•-------------- --• ---
Design Flow ............. ____......................gallons per person e day. Total dailyflow ....... gallons.
Septic Tank —Liquid capacity gallons Length__?_ Width._ `�i.. Diameter___"'"`.__._. Depth. '80._
Disposal Trench — No. ________ ......... Width .................. Total Length .................... Total leaching area______:..._ .. sq. ft.
Seepage Pit No ............. Diameter......._.__.__ Depth below inlet...'*_____..
p' .. Total Teaching area_ ....... ft.
Other Distribution box ( Dosing tank )
Percolation Test Result Performed by.___. _ __ . __1t _ �_.... � _______.•__- Date. _ "_ -P&
Percolation
Test Pit No. 1_____ _________minutes per inch Depth of Test Pit .... JA _________ Depth to ground water_.__
Test Pit No. 2................minutes per inch Depth of Test Pit .................... Depth to ground water ---- *1*4"Fk,
--- ---
Description of Soil___________________ ' + ' - --
Nature of Repairs or Alterations — Answer when applicable.................................................................
Agreement:
The undersigned agrees to install the aforedescribed
the provisions of TITLE 5 of the State Sanitary Cod '
operation until a Certificate of Compliance has bee issed,
Application Approved By
Individual Sewage Disposal System in ac
hundersigned further agrees not to place
� the board of h
Application Disapproved for the following reasons: ...................
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Permit No. ---i.- ._ ._ a -----------------•-•.._..
ALLYN
16
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Dat
_._._ .........-
Date
Date
Issued---.'-!.------ .......-------------------- ------
Date
THE COMMONWEALTH OF MASSACHUSETTS
BOARD HEALTH
...... OF ......... a, ..............................
Tn tifiraU of Tompliaure
THIS IS TO CERTIFY, That the Sewage Individual Se Disposal System constructed ( or Repaired ( )
_. g
�%� I Insta f
-----------------------
has been installed in accordance with the provisions of TIT� ''' 5 of The State Sanitary Code as described in the
application for Disposal Works Construction Permit No ......... .-:___,4',2e�.......... dated___.,,R-:4!,'�—v'___-_elF---------------
THE ISSUANCE OF THIS CERTIFICATE SHALL NOT
� BE CONSTRUED AS�,
THE
SYSTE yV UNCTION FACTORY.
17. octey
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