HomeMy WebLinkAboutApp-Permit-Compliance1 .�.� . Lo �.� Fps.. `� S
No. .._ .
THE COM ACHUSETTS
BOARD OF HEALTH
..lip iration for Dhipoiial Works Tonstrnrtion ramit
Application is hereby made for a Permit to Construct (k<or Repair ( ) an Individual Sewage Disposal
System at:
- .. ---
�% Location Address ^g+ •�. / -�'�` or Lot No. �� y
.....5.:.r....jn.� .. ! ase ..`------- -.[..+__./......� d""_ ___ Q -h �.. . °esJ: t Y�i i -_•_ cL _ ..N E�
Owner !_ Addres
si!`:! - 4 !_'Q� � -'F __ijr �? 9 1� �i.+^� J C E► '� n s ✓✓J
Installer Address
Type of Building Size Lot._�_�F_,.Sq. feet
Dwelling — No. of Bedrooms ___......... �.........................Expansion Attic __7 Garbage Grinder R(��
Other — Type of Building .__sL._____ No. of persons .._._.... (0 ............... Showers ( ) — Cafeteria ( )
Otherfixtures--------------------------------------------------------------------------------------- ------------------------------------------------•-----------•-
Design Flow ................. ��_............. gallons per person per day. Total daily flow_..._____. �4_ 0..................gallons.
Septic Tank —Liquid capacity)4a%.gallons Length�___.(0..__. Width.�...1 o'._ Diameter-___-___-____- Depth._ ._ 8
Disposal Trench — No . .................... Width .................... Total Length ................. __. Total leaching area .................... sq. ft.
Seepage Pit No --------- 1-_-------- Diameter ...... &-____-___- Depth below inlet ...... k.......... Total leaching area_._ 2!9� ...sq. ft.
Other Distribution box (v -r Dosing tank
Percolation Test Results Performed by__.........!..`_Sl_� �r______ `5 ....! ____._. Date_______'��. ?' & 0
---•----�--------...
Test Pit No. 1____ 6__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 ............ am(--- __}�
--------------------------•-----........ _ 4
4 CI S
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Nature of Repairs or Alterations — Answer when applicable .________________________________
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Agreement: ,
The undersigned agrees to install the aforedescribed Individual Sewage Disposal, System in accordance with
the provisions of 'TTLE, y g g p y
5 of the State Sanitary Code —The undersigned further agrees not to lace the system in
operation until a Certificate of Compliance hays been, issued by the board o�lth.
/V Application Approved BY- -- --- ------ - - ---- ---------------------- ----•----------------------------------------�--D
Application Disapproved for the fol owing re ons-----------------------•-------------------------------•---------------.........................................
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Dat
e
QQ -
Permit No ------ L:J_1`1.5- ! y--•------------------------- Issued.-------------�� Dat
of ............
e
THE COMMONWEALTH OF MASSACHUSETTS ��JLQ 7--
BOARD OF HEALTH /.--/
..........................................
Ct ntifiratr of (1 ontlrftanrr
THIS IS 7.0 CERTIFY, That the Ind vidu 1 Sewage Disposal System constructed (�r Repaired ( )
by....�'........-�'f-1 v.- :.,.� &C' -------- � � U �a ,.>
• ----- - --- -----------------------
J �, ....1 .�'a -� g i•--> Inst t .4
has been installed in accordance with the provisions of TITLE j of The State Sanitary Code as described in the
application for Disposal Works Construction Permit No ......................................... dated __..______.-._______.___________---_-.-_-_--•--.
THE ISSUANCE OF THIS CERTIFICATE SHALL NOT BE CON UED AS A GUARANTEE T THE
SYSTEM WILL FU,)ICTIO,N SATISFACTORY.
DATE..------... I..../...Inspect -- .
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