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HomeMy WebLinkAboutApp-Permit-ComplianceI THE COMMONWEALTH OF MASSACHUSETTS -y-'- BOARD OF HEALTH ......... f-..Q.GAG�--------..OF.... f.��....�LQ�!71---------------------------------- ------ ------ ApplirFatiou for UWVv5al 10orks Tonotrnrtiun ramit Application is hereby made for a Permit to Construct ()() or Repair { ) an Individual Sewage Disposal .....------Y�to�Tr a _ !_� /_ -•- 0 A StPitl at Location Address o LotN o. y -� 1-7! Y ..... 16 Address ..........................................•. installer Address eof Building Se lot% ©_. g©....Sq. feet U Dwelling—No. of Bedrooms.............3........ ................. Attic ( ) Garbage Grinder ( ) 04 Other — Type of Building ............................ No. of persons ............................ Showers ( ) — Cafeteria ( ) Q' Other fixtures .-•---•--•--•--•--•-•••••-••-•---- W Design Flow ----------------------- --------. .....gallons per person per day. Total daily flow .................... 33.0........... Ions. s� R: Septic Tank — Liquid capacityt�_0Q�___.gallons Length. tt_rr.. idth _� j.Qr' ... Diameter ................ Deptl ....__--4._. Disposal Trench — No. -____-•_-_----•-- Width...._... __.. Total Length .................... Total leaching area..... -•---•-_-------sq. ft. i Seepage Pit No ........ I._-___-____ Diameter.16_'f.2._..... Depth below inlet --_--............. Total leaching area ....�2_ ........sq. ft. Z Other Distribution box (X) Dosin tank ( ) '-' Percolation Test Results Performed b ._.,g�`GV 4..... MAQWf V..... Date.11AR- l 2 1�7� Y�� - a Test Pit No. 146fl.Z..rninutes per inch Depth of Test Pit-l6_�_.______ Depth to ground water._ Test Pit No. 2 ----------------minutes per inch Depth of Test Pit .................... Depth to ground water ........................ h---------------------------------------------- --------------------------------------- --------------- --------------------------------------------------------- - .s Description of Soil---.... 0-f.-AW-01.VAN...%_/�'--CO._ �Q�P __47 �-----U -'� ---------------- Nature of Repairs or Alterations — Answer when applicable ................................................................................. _.............. -----------------------------------------------------------•------------------------------------------------------------------------------------------------------------------------..........------•--- Agreement : The undersigned agrees to install the aforedescribed Individual Sewage Disposal System in accordance with the provisions of iiTE 5 of the State Sanitary Cod The undersigned further agrees not to place the system in operation until a Certificate of Compliance has en i sed by • of health. Signed7S Date Application Approved By ......................................... --- --- ---•-• - ---..........5--^-4t1�?7. Date Application Disapproved for the following reasons----------------------------------------------------............................................................ ----------------------------------------------------------------------------------------------------------•-•---•-•---•-••-•-••-......................................................... Date PermitNo ......................................................... Issued ....................................................... Date THE COMMONWEALTH OF MASSACHUSETTS BOARD/�/f­ HEALTH ......... .....4q.A*1...... OF......# ........................ ..... ..... .............. ....... farr�ifirtt� f?�rrnt�ft�atr�e �,� the Individual Sewage Disposal System constructed .-) or Repaired ( ) THISIT�R r ,..rte" _"__ _ ---------------------------------------------------------------- -- ------------- at r g,✓f nsta has been installed in accordance with the provisions of TITLE j of T e State Sanitary Code as described in the application for Disposal Works Construction Permit No..' dated dated___'". "'.-_____________ THE ISSUANCE OF THIS CERTIFICATE SHALL NOT BE CONSTRUED AS A GUARANTEE TJ9AT THE SYSTEM WILL FUNCTION SATISFACTORY. DATE................................................................................ Inspector