HomeMy WebLinkAboutApp-Permit-ComplianceTHE COMMONWEALTH OF MASSACHUSETTS
BOARD OF HEALTH
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Apptiration for Dispntitt1 Works Tonotrurtion pamit
Application is hereby made for a Permit to Construct (X ) or Repair ( ) an Individual Sewage Disposal
System at :
'C'T S S 3 Pc�/�S ETTIA DRi VF l�!77 t�:_. 7. - - -- -
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Locat on - Address ort No.
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Q Ownerdress
a Installer Address -
QType of Building � Size Lot -VI----- -•.....Sq. feet
aDwelling — No. of Bedrooms -------------------------------------------- Attic ( ) Garbage Grinder ( )
p, Other — Type of Building ............................ No. of persons ............................ Showers ( ) — Cafeteria ( )
W� Other fixtures .--•---•------------------------------------•--•----------------------------------------------------•-----------...-----------•--------...---------•
W Design Flow-•------------- -----••-_-:--SJ....gallons per person per day. Total daily flow __-_-----_----_-----_34 P---•--__gallo .
W Septic Tank — Liquid' capacityl ODdf _gallons Length _ -�.____ Width4_�� 04.. Diameter ................ De the " `f"_..__.
x Disposal Trench — No. -_-•--_---•----_-- Width .................... Total Length .................... Total leaching area
.................... sq. ft.
Seepage Pit No. ........ I.......... Diameter.6(f2•.1..... Depth below inlet ._+'...._..._._. Total leaching area.=�r�o.......... sq. ft.
Z Other Distribution box ()() Dosing tank %
'-' Percolation Test Results Performed by .... 1!!�___ 5.5E ........................................... Date.. 1slez-.___.__.__......
L .minutes per inch Depth of Test Pit__ S._0..Depth to ground water
Test Pit No. 1.._f 2 p p P%�
(s, Test Pit No. 2................minutes per inch Depth of Test Pit .................... Depth to ground water ........................
W•--•----•-•-•-----------••------------•--••-------••-•--•----•-....._....-•-------•----------------- .........................................................
Description of Soil - rL A%Y_..1%E � E S N Alb CLGa IV .. F/N 3A/di 0..........
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011 419,�OdLo-----------------------------------
W------•----•------•--------•------------•--•-----------------------•-----••-----•-------•---••---------••--•-------------------•-------------•----•---•--------•-----------•----------•-----•---------.
UNature 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 TITLE 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.
Signed. _ -------------- ................................ -- -••----._�1"Z-...._
Application Approved B . ---•--•-. -----------
--•••.•-•--------------••-•-•.....-------•-•-•----• -•--• --•-•----
PP PP YIII/// ate
Application Disapproved for the f ollowin reasons:--------•------------------------•--------------•----------•--•------------------------------------------•---
----••-------••------------------------------•--•-•----•----------))--------•----------------•--------------------_..-----------------------•------------J-'---- ---------- --••-----•--Date-•---•----•---
Permit No. '--- ---------• Issued--------- 1 a
Dat
THE COMMONWEALTH OF MASSACHUSETTS
BOARD OF HEALTH
.......................................... OF ........................... ....... :" ........ ---1 .........
Trrfifira tr of Toutphancr
THIS IS TO CERTIFY, That the Individual Sewage Disposal System constructed ( ) or Repaired ( )
bY--------------------------------------------------------------------------------------------------------------------- -..............................................................................
Installer
at......................................................................................................................................................................................................
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 CONSTRUED AS A GUARANTEE THAT THE
SYSTEM WILL FUNCTION SATISFACTORY.
DATE............................................................................... Inspector ............................................