HomeMy WebLinkAboutApp-Permit-ComplianceNo. 9-A------- FEs.. : � .---
���� THE COMMONWEALTH OFMASSACHUSETTS
BOARD
✓OF HEALTH
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Appliration for Disposal Works Tongtrnrtinn Frrmit
Application is hereby made for a Permit to Construct (K or Repair ( ) an Individual Sewage Disposal
System at:
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Location -Add ess or Lot No.
✓-5- 4!•92 �tJ7'7'7
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caner
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Installer
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Address
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Type of Building Size Lot ............................ Sq. feet
Dwelling — No. of Bedrooms .......... �r............................ Expansion Attic CiLb) Garbage Grinder OLbk)
Other — Type of Building ____________________________ No. of persons ............................ Showers ( ) — Cafeteria ( )
Otherfixtures-------------------------------------------------------------------------------------------------------------------------------------------------
Design Flow ..................... S_`>_____________gallons per person per day. Total daily flow --- �A ��G'_ Z ____.__57-e'.' gallons.
Septic Tank — Liquid' capacity/gallons Length___ __ �Width__ 4- _Z'0_Diameter____________ Depth___ ____ __.___
Disposal Trench — No_ ____________________ Width .................... Total Length .................... Total leaching area____.____ _____. __sq. ft.
Seepage Pit No ...... /------------ Diameter ......... °__ Depth below inlet_3c�7_"Total leaching area__ _sq. ft.
Other Distribution box ( Dosing tank
Percolation Test Results Performed by;56_ --� -- �-------- /12
OF
Test Pit No. 1 ________________minutes per inch Depth of Test Pit .................... Depth to ground water_'____ e. _. .....
Test Pit No. 2___-' - ._minutes per inch Depth of Test Pit___, _______._ Depth to ground water___ ___.RGGER
PAUL
...............................................
Description of Soil ___________________0.7.3.' 73'2_.
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Nature of Repairs or Alterations Answer when applicable ............................................................. ____
CIVI
----------- -------------- ---•- ---- --- -•---- --- -----................. ....... --- -- -- ----
Agreement:
The undersigned agrees to install the aforedescribed Individual Sewage Disposal System in ac dance wit
the provisions of TITLE 5 of the State Sanitary Code — The , dersigned further agrees not to place the system in
operation until a Certificate of Compliance has been ue b board oj health.
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Si ed -_lam _-'------••--
/��Date te
Application Approved By- - - ... •-.._._.._...-------•-••-...•-------------•• ----
Application Disapproved for the following reasons----------------------------------------------------•----------•---------------•-----•------------•-------------
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Q Is_s_'u__e_
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Permit ---•-------------------•--- -.Z.-
Date
/
THE COMMONWEALTH OF MASSACHUSETTS (/ -
BOARD F HEALTH
.................. OF .... .....'1�Lf,?..._._..__......_...__..............
(9rdifirtt#le of Tomptiaurr
THIS IS TO CERTIFY, That the Individual Sewage Disposal System constructed V111"Or Repaired ( )
at ---1 ---•-_ ----;=------ -=----•-----------------------•---------•---------------------------- ----------...__........ ..----------------------------------------• -----•--------------------
has been installed in accordance with the provisions of TI T I,E 5 of The State Sanitary Cod a d scribed in the
application for Disposal Works Construction Permit No.__!__.:___%' rt'.____.___. dated___. n' _� . _.
THE ISSUANCE OF THIS CERTIFICATE SHALT. NOT BE CONSTRUED AS A THAT THE
SYSTE FUMC_TION TISFACTORY. ci
DAT7-_�_ .._....._-••------------•--•-------- Inspect