HomeMy WebLinkAboutApp-Permit-ComplianceNo. gB a9a ... Fxs. _...._......_
THE COMMONWEALTH OF MASSACHUSETTS
BOARD
�OFHEA.LTH
.....:../)y�
.. .
Appliration for Disposal Works Tonstrartion f rrutit
Application is hereby made for a Permit to Construct ( ) or Repair (X) an Individual Sewage Dis oral
System at:
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-v U (//v oc do -Address
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Owner
----------------------------------------
Installer
Type of Building
Dwelling — No
Other — Type
Other
til %�' DoT 4� -73
` or Lot No.
Ad ress
Address
Size Lot____________________________Sq. feet
of Bedrooms ......... ............................. Expansion Attic ( ) Garbage Grinder ( )
of Building ............................ No. of persons ............................ Showers ( ) — Cafeteria ( )
fixtures
-----••-_-•-•••. •-------------.............................................................
Design Flow............................................gallons per person per day. Total daily flow ............................................ gallons.
Septic Tank —Liquid* capacity ............ gallons Length ................ Width ................ Diameter ................ Depth ................
Disposal Trench — No ..................... Width .................... Total Length .................... Total leaching area .................... sq. ft.
Seepage Pit No ..................... Diameter .................... Depth below inlet .................... Total leaching area .................. sq. ft.
Other Distribution box ( ) Dosing tank ( )
Percolation Test Results Performed by .......................................................................... Date ........................................
Test Pit No. 1................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 ........................
Descriptionof Soil---------------------------------------------------------------------------------------------------------
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Nature of Repairs or Alterations/—Answer when applicable....../Joe __�'�.R___.__?���7C–....._7!*v.<...............
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Agreement:
The undersigned agrees to install the aforedescribed Individual Sewage Disposal.System in accordance with
the provisions of TITIE 5 of the State Sanitary Code — The undersigned further agrees not to place the system in
operation until a Certificate of Compliance has n ' ed by
board o health.
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ate
Application Approved By4�`? ................................ ..:......... ......•--._..__....--•--...---•-----...._... �0/ J9 .0
Date
Application Disapproved for the following reasons: ----------•-------------------------------------------------•----------.....------------------...._..•--------
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ate
Permit Nom.. 221---------------------------------- Issu 19g
THE COMMONWEALTH OF MASSACHUSETTS
BOARD OF HEALTH
Trrfifiratr of Tomplinurr
THIS IS TO CERTIFY, That the Individual Sewage Disposal System constructed ( ) or Repaired (X)
by...... ........ r i2 --------------------------------------------------•-------•-----------------------------------...---------._..._....-•------------
Installer
at.......... r2_..4? SL vr� u v n .....................................................
has been installed in accordance with the provisions of T a E dr f The State Sanitary C. e scr3'�e��jj e
application for Disposal Works Construction Permit No-i'.1
o.i'-Q-"r�_l_�___________________ datec ...... o�f.L -----
THE ISSUANCE OF THIS CERTIFICATE SHALL NOT BE-C–ONSTRUE® AS A G ARANTEWtHAT THE
SYSTEM WILL FUNCTION SATISFACTORY.
DATE .....�~.� ._.._... Insp'ectA�.!'`! ==----------•---