HomeMy WebLinkAboutApp-Permit-Compliance�0- .....
THE COMMONWEALTH OF MASSACHUSETTS
,% ---- BOARD PF HEALTH
.... OF ...... ................................
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Appliration for Uispaoal Works Tonstrurtion 1hrmit /
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Application is hereby made for a Permit to Construct or Repair ( �n Individual Sewage Disposal
System at
........................
Location -e
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.............. .......... --- Icy- IQ ................
0
............... .. ftD ......
Installer
Type of Building
Dwelling — No.
Other —Type i
1: S
.......... v=f--------------
0, ( a TR
... 01e.6a'). ------ or. fnbw
ress
- ----- .. .... ........... . ... . . is ............
Address
Size Lot ............................ Sq. feet
of Bedrooms..... . 4 .................................Expansion Attic ( ) Garbage Grinder
E Building ............................ No. of persons____________-_______________ Showers ( ) — Cafeteria
Otherfixtures ......................................................................................................................................................
Design Flow ............................................gallons per person per day. Total daily flow -------------------------------------------- gallons.
Septic Tank — Liquid capacity 150CIallons Length________________ Width___________..___ Diameter._____._.____.__ Depth__......._..._..
Disposal Trench — No ..................... Width .... -------- Total Length___..__..........___ Total leaching area .................... sq. ft.
Seepage Pit No -------- _1 ......... Diameter.__.._'-.______. Depth below inlet .................... Total leachingaV%. sq. ft.
'Other Distribution box Dosing tank
Percolation Test Results Performed by .......................................................................... Date_.....___________
ff,;5
Test Pit No. I ................ minutesperinch Depth of Test Pit_._.________________ Depth to ground water.Xb.,n_,., .
Test Pit No. 2 ................minutes per inch Depth of Test Pit_______......_._.__. Depth to ground water_.-________._._.._.._..-
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Descriptionof Soil ................................................................................................................................................................. ......
.............................................................................................................................. ..........................................................................
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Nature of Repairs or Alterations — Answer when applicable ------------------------------------------------------------------
.......................................................................
Agreement:
The undersigned agrees to install
f mTIPT 7, 4; -f 4-1— q+,+A
the provisions u - 1
operation until a Certificat
Application Approved By
Application Disapproved f
the aforedescribed Individual Sewage Disposal System in accordance with
qnn;fnrxr CrAA — T11.- 11"C1F-r.-,10rnPd fiirthpr nprees not to nlace the system.in
...................................................................................................................................................................................
Date
Permit No -X7--3 V6 Issued�,�,1�__ 44U ................
................................................... Ea'te
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THE COMMONWEALTH OF MASSACHUSETTS
BOARD OF HEALTH
....6*A) .......................... OF.., ".-rw .......................................................
..........
(ffrrtifiratve of Tompliaurr
�gS�S TO CERTIFY, That the Individual Sewage Disposal Systern constructed or Repaired----------------------------------------------------------------------------------------------------------------------------------------
by........... ................... Installer
ad -3.1 ---
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has been installed in accordance with the provisions of TITLE 5 of The State Sanitary I� o _eas d scrd * the
application for Disposal Works Construction Permit No._37=_S� _--------------- dated, .......
THE ISSUANCE OF THIS CERTIFICATE SHALL NOT BE CONSTRUED ASA TEE THAT THE
CTION SATISFACTORY.
SYST 'LL
DAT-90 .............................. Inspect ........ . . . ......... .... ....... .......... I .................