HomeMy WebLinkAboutApp-Permit-Compliance-1�5 � o�
No. ! �----__...... Fss_.,I. ..........
TH�L� ;OMMONWEALTH OF MASSACHUSETTS
BOARD OF HEALTH
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Appltration for Disposal Works TonsUwtion 1rrutit
Application is hereby made for a Permit to Construct ( ) or Repair ( tan Individual Sewage Disposal
System at: 4Q J
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Location . Address or Lot No.
............. . `�� :e:........Tc.S!5!Z.'r ........................... ................................................................... ........
Owner Addr
---•..... G�?'r .. V_ •------------------•--••-------•------.!��.�.�.._'�.0�--���t..................................
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......... �'6...-......................gallons per person per day. Total dai y flow........ � ...._........_..._--gallons.
Septic Tank -S- Liquid' ca.pacit .I'- Length _..... p
allons Len h__.._ Width ..... ........: Diameter__._...__..._._. Depth
Disposal Trench — No. .3. G . Width ........ ....... Total Length ..... arV........ 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 ........................
Description of Soil ............................
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-..--------------------------------------------------------------------------------•-------------._...---•------•--..•-----•--. ------------. ----
UNature of Repairs or Alterations — Ans er when applicable....-l�'1�7�}...1. .c�.v.. "r �'\ -..........
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Agreement:
The undersigned agrees to install the aforedescribed Individual Sewage Disposal System in accordance with
the provisions of TIT1Z- 5 of the State Sanitary Code — The undersigned further agrees not to place the system in
operation until a Certificate of Compliance has bee�issued�he board f health.
Signey` `..`.....
Application Approved By -----
-- -•--........-•-•-•---.._..--•-•---••.._..._ ....._. ..........
Date
Application Disapproved forreasons: ...........................................••-_-------------...--.---•-------............_..._................-
..••----...-••-•-•••............................•-•-••---.-.---••----•----...---...-•-----••---------•--•.......-----._.........---•-••------•-.--•--.... --- - ------------
Permit No. - -'I� ] % j►
------------•-_ Issued - ---------- 1. ---- ------ (J -.-.-.-.
--./.�(Date ------
D
THE COMMONWEALTH OF MASSACHUSETTS
BOARD OF HEALTH
........... OF .... (a r...... v �'.........................................
Tnrtiflratr of Tomplianrr
THIS IS TO CERTIFY That the Individual System Sewage Disposal stem constructed
P �'
Installer
at........................... ...-_f�..l.t.�. S..........................................:SU- •-� to re t ut.. ...........
has been installed in accordance with the provisions of TIT,5 . The State Sanitary Cc
application for Disposal Works Construction Permit No....._'�1I1-:'1.l................. dated ...... .
THE ISSUANCE OF THIS CERTIFICATE SHALL NOT BE CONSTRUED A U
SYSTEM W1 FUjNC.VION SATISFACTORY.
DATE. ............ .L................................................... Inspector.
) or Repaired ( �
...... ............................
as described in the
L�---------------------
to TEE THAT THE
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