HomeMy WebLinkAboutApp-Permit-ComplianceNo....5�.7-.3c�0
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THE COMMONWEALTH OF MASSACHUSETTS
BOARD OF HEALTH
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Appliration for Uhipasal, 19orkg Tonotrudion pamit
Application is hereby made for a Permit to Construct ( ) or Repair (jO an Individual Sewage Disposal
System at • ,� A �o
Location - re
dd..-. y ,,. or Lot
own Addr s
. Z. ... v= ��.r91
...........................
Installer Add as
Type of Building Size Lot ............................ Sq. feet
Dwelling —No. of Bedrooms........... rl ...........................Expansion Attic ( ) Garbage Grinder ( )
Other — Type of Building ............................ No. of persons ............................ Showers ( ) — Cafeteria ( )
Otherfixtures ..............................•---•••-•--......-•--.••.............•-••-•..............._........•-•--....---...•••-•........--•-•-------..........
Design Flow .... Zd.0-A4 ..- 5'Y- ..•.. gallons per person per day. Total daily flow .....�4_ 40 .......................gallons.
Septic Tank — Liquid capacity ............ gallons Length ................ Width ................ Diameter................ Depth .................
Disposal Trench — No ..................... Width.................... Total Length .................... Total leaching area ...................sq. ft.
Seepage Pit No......../P........ Diameter ......... 1,�......_ Depth below inlet ..... 4...........Total leaching area:&,7/..... sq. ft.
Other Distribution box ( ) Dosing tank ( ) 7W 6A0
Percolation Test.Results _ Performed "by .......................... ....... Date 2.....: ...........:
Test Pit No. l ................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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Description of Soil ............ X0.1V.O.,d�!...... �...... ce. -Owe's . /1 �..........................•----..............--------••----........
-•-• --•••-•---••-•--••--...-••-...--••••.....................•--• •• • •••..............--•----•-••••-••• •-•---
of Repairs or Alterations — Answer when applicable__r!114Z
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 has7..-.
issued by the board health.
Sign] l- - = --.... ^..- ..............•----..
�7
Application Approved '$
PPy---.._.:.... ......................................................._ _.._._�_..-/-.-----
ate
Application Disapproved for the f oll reaso
...--•----•---•.............................•--••------.............-•---...............--•--------..._............................................................................................. _
Permit No..-.....�.....7 Issued.......... ....?,L . .
Date
Tig,.,COMMPNWEALTH OF MASSACHUSETTS
BOARD OF HEALTH
TlY
J' r faFrfiftrtt#r Itf IIln titunrr r ,
Thl S IS�'�T�' E TIFY, That the Inu vidual Sewage Disposal System constructed ( ) or Repaired `(
by..`frt�t:rY__ l,; �1.. ...._ ...... ...
3
;.. .
has been installed' in accordance with the, provisions of T l5 0(1 The State Sanitary Code as escrib #, the
application for Disposal<Works Construction Permit �'o... . :._._................
dated _' j.�k`-- �
THE ISSUANCE OF THIS CERTIFI6ATE SHALL NOT BE CONSTRUED AS_AAG"Ri WT E;THAT THE
SYSTEM WI LF N TION SATISFACTORY.
t"
t DAT ��` ... � .... --.... , Inspector.....::. .: ...._...
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