HomeMy WebLinkAboutApp-Permit-ComplianceTHIII ONWEALTH OF MASSACHUSETTS
BOARD OF HEALTH
Tk�?7 .
_ ......
Applirati n for Uiapao tl Works Tonstrurthitt thrmit
Application is hereby made for a Permit to Construct (X) or Repair ( ) an Individual Sewage Disposal
System at:
1-kl�. - t fo l _o? ...... ........... C a PT :.... cTM i4 L `....... R®q lJ ............!----.t. ...................................
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P " .. ...................
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h owner Address
--�•------------- -1_ ...... --•--------.....------------............................................................ .....................................
Installer Address
Type of Building 3 Size Lot._ at..4 97....Sq. feet
Dwelling —No. of Bedrooms............................................Expansion Attic ( ) Garbage Grinder ( )
Other — Type of Building ............................ No. of persons ......................... Showers ( ) — Cafeteria ( )
Otherfixtures-----•------------------------------------------•-----.-•--------••--•-•---•--•-•-•-•-•------
Design Flow.............................s�-4'---..gallons per person per day. Total daily flow .__......_._...._.......3ZS ------- gallons.
Septic Tank—Li uid'ca acitY-4•aA_ allons Len th_ `-&" Width-IL0" Diameter ................ Depth -1
�-•---
Disposal Trench — No ..................... Width-------------------- Total Length .....................Total leaching area .................... sq. ft.
Seepage Pit No ........ %........... Diameter.6... . �..... Depth below inlet ..+1.......... Total leaching areal .....sq. ft.
Other Distribution box ( Dosing tank
Percolation Test Re ults Performed by___sllS%Lf!e.................. Date--. l:� -1 Ay 1)
FT ----------------- ,,,, JJ
Test Pit No. ...4Cff2 minutes per inch Depth of Test Pit.../.2(...... Depth to ground water;V;;"Z0�T7�e
Test Pit No. 2 ................ minutes per inch Depth of Test Pit .................... Depth to ground water ........................
Descripp-tion of Soil .....-�G- M..__..m ----------------_---- --------------------------------------------
UA/f� - -���y - Q!ta l
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 TIT 1Z- 5 of the State Sanitary Code Th nder ' ed rther agrees not to place the system in
operation until a Certificate of Compliance has been d e oar of �ealth.
QSied----- -------- --•--- -- . -- -- . --•------------••----...--•-- .�. .l l..__....
Application Approved BY ---1.A-.:•--------_ -••---• ----------------•---------------- el
Date
Application Disapproved for the following reasons:----------------------------------------------------------------------------•-------..................._.._..._
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_-Date
i f
Permit No....� l S .. Issued a D"_�.---.-----...........
----------------------------
ate
THE COMMONWEALTH OF MASSACHUSETTS ,
BOARD OF HEALTH �) t
.......................................-OF .....................................................................................
Trr#ifirtttr of fel mptiaurr
THIS, IS TO CERjiFY, That the Individual Sewage Disposal System constructed ( ) or Repaired ( )
- /` taller
at----------------CJS./._!-------11 G---------•----------------------------........................----------------........
has been installed in accordance with the provisions of TITLE 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 BE QQNSTRUED AS A GUARANT ,THAT THE
SYSTEM WILL F NCTIO SATISFACTORY.
DATE ......------• iL�
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