HomeMy WebLinkAboutApp-Permit-ComplianceNo. 8...... 3 a�-�
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Fims............._....
THE COMMONWEALTH OF MASSACHUSETTS
BOARD OF HEALTH
--......OF .......... th!4C)..........................................
Appliration for Disposal Works Tontrudion 1rrnti#
Application is hereby made for a Permit to Construct ( ) or Repair ( ) an Individual Sewage Disposal
System at
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1 Location - Address or Lot No. O/
-------....:�i'd::51. :....!!k..._�j 1A=L,.......................... -'w - ----------_.-------------------------------------------
0,
......_._.__... --........-----...- b
Owne! Address
.............. .i4: =�'--------- {----------------•--------•-------- ssrn.h�:�................................................
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 ......._.. 0 ................. gAlons.
Septic Tank — Liquid capacity ............ gallons Length ................ Width ................ Diameter ................ Depth ................
Disposal Trench — No ..................... Width .................... Total Length .................... Total leaching area ........... _-__----- sq. ft.
Seepage Pit No --------- J........... Diameter.__.._ __..__. Depth below inlet____y______r __________ 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 ........................
Descriptionof Soil .................................................................................................................................
•----•----•-------------------------------------•-------------•---•---------------------------•--------------------------------------...---------------•----•---•-----------------....-----••• -•-•••---
Nature of Repairs or Alterations — Answer when applicable .... 1�.�._ i
4w.c.-........ o- ...... ..--- Sr?oQ'/ .=-----------------------•--------------------------------------------.......-----.....
Agreement:
The undersigned agrees to install the aforedescribed Individual Sewage Disposal System in accordance with
the provisions of iITIS 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 he lth.
Signed.-- •- ------------ ------ ----•------- ---- -----• ....................
Application Approved By ............
eDat�
................. _._.
Application Disapproved for the f oilowiAo reasohs-------------•--•-•-•-----._._._...-•----------•--------•---•---------------------------.._..._._________
Date
PermitNo ............................. ................ Issued------------ -l_..._...._.
Date
THE COMMONWEALTH OF MASSACHUSETTS
BOARD OF HEALTH
'.........OF..........).........................................
Trr#ifirtttr of Tontphaurr
THIS IS TO CERTIFY, That the Individual Sewage Disposal System constructed ( ) or Repaired
�
by............................. . A �f'A � ---------- Y------•----.._.._...-----...--------•---------------------•---------•----•--------....
Installer
at 1.14'1711.v ...... .A -------------------- C U �k�'G�!'` � �! ..............................
has been installed in accordance with the provisions of TITIN; 5 of The State Sanitary Code as described in the
application for Disposal Works Construction Permit No ----------------------------------------- dated ................................................
THE ISSUANCE OF THIS CERTIFICATE SHALL NOT B _1;ONSTRUED AS A GUARANTEE THAT THE
SYSTEM WILL FU CJIONP;!SFACTORY.
DATE._..---------------------- ------------ --•--------- InsPec ` �� -- 7...._.....:_..:.