HomeMy WebLinkAboutApp-Permit-ComplianceNo. .`.371--- Fes$....../..S_..... . ....
THE COMMONWEALTH OF MASSACHUSETTS
BOARD OF HEALTH
...................... OF......Y : V. ........
Appliration for Disposal Works Tonstrur#tun rrrntit
Application is hereby made for a Permit to Construct ( ) or Repair
(✓) an Individual Sewage Disposal
System at:
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ppLocation -- Addressor
Lot No.
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� Omer / • Addreess
...W.A]--•-AAodk._lC. ..-•--•-. - .:................
> ...... 4.�� --f I is4I ! ..._.. - ...... ...'9r&
Installer Address
Type of Building
Size Lot ......................:..... Sq. feet
Dwelling —No. of Bedrooms .................. . ..................... Expansion Attic
( ) Garbage Grinder ( )
Other — Type of Building ............................ No. of persons ............................
Showers ( ) — Cafeteria ( )
Otherfixtures -------•-----•-------------•-------•---••----._.....--•------------------------------
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. I................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 ........................
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Descriptionof Soil ........................................................................................
...................................................................................................................................... -.................................................................
Nature of Re airs or Alterations — Answer when applicable_ -__N -k t___.SgA u__.f y.sreo!1_._._t OQd__6ST'_.p __4�0-X
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Agreement:
The undersigned agrees to install the aforedescribed Individual Sewage Disposal System in accordance with
the provisions of 'JI TM 5 of the State Sanitary Code — The undersigned further agrees not to place the system in
operation until a Certificate of Compliance has been issued by the board of health.
Application Approved By
Application Disapproved for
Signed..
.....................................
ate
Permit No..09 '
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------ Date
1 YIssuVCAZ
- ..._._...
Date
THE COMMONWEALTH OF MASSACHUSETTS
�- BOAR\D� OF HEALTH
...!....w!U.........................0 -1 1 ...'MDU............................-•---...-•-•-.---..........
(P n ifiratr of (1 outs haurr
THIS._S_ CERTIFY, That the Individual Sewage Disposal System constructed
by- .iJ��L�4!�.St�SJ6
-----------------------------------
--------•---•--•------------------•-•--•------ ----------------
3 Y I staller
at..).Jj WEST _..J f!!r!'!Qkf2NQ1-- ��S%-----]'A�tifCIA ................... ....
has been installed in accordance with the provisions of T T rr11r f The State Sanitary
application for Disposal Works Construction Permit No-.�'� a _____________________ dated
THE ISSUANCE OF THIS CERTIFICATE SHALL NOT BE CONSTRU
SYSTEWWILL r7�CTION . SATISFACTORY.
DAT _.- Inspectoz-.e��.1---- --=
) or Repaired (,X)
..............
W( c >< the
........
RAN EE THAT THE
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