HomeMy WebLinkAboutApp-Permit-ComplianceTHE COMMONWEALTH OF MASSACHUSETTS
f BOARD 9F HEALTH
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Applira tion for Diopnlital Worka Tomitrurtion ramit
Application is hereby made for a Permit to Construct ( or Repair ( ) an Individual Sewage Disposal
System at
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.�LocatiOwneddress eq — A �tNq
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Installer Address
Type of Building Size Lot- 2; /._%1F.._ Sq. feet
U Dwelling — No. of Bedrooms-------------------------------------------- xpansion Attic ( ) Garbage Grinder (1�)6
Other — T e of Building ............................ No. of persons ............................ Showers — Cafeteria
a Other fixtures .................... . . .
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W Design Flow .................... ..............��gallons per person per day. Total daily flow......................... ;L;Z.0.... gallons.
WSeptic Tank — Li uid ca acit ./1P9gallons Len th.2"6.1. Width._15/:A4_.. Diameter ................ Depth ..... ........
x Disposal Trench — No. ._ ................ Width .................... Total Length ...... __>>__.__.____ Total leaching area .................... sq. ft.
Seepage Pit No ....... /........... Diameter ....... ,1Q...... Depth below inlet ....... Total leaching area..A.-fe_ .7..sq. ft.
Z Other Distribution box (X-< Dosing tank ( )
'-� Percolation Test Results Performed bY......................................................................... Date ........... .............................
aTest Pit No. L'�"_2--__.minutes per inch Depth of Test Pit._ ��{�__ Depth to ground water -..A).0-_------.-.
Test Pit No. 2.-_ -.minutes per inch Depth of Test Pity ��__.... Depth to ground water -__N o..........
C47_'&Jt•I__ d-= .Go. �S�.bs� r 1 •�_ ou F itiE..f� t�AJ -� 4t0
D Description of Soil.. ill--'.".-:.11--�d-----4-442Z&Z----- fl- ep .....JANQ._r...11
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UNature 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 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 is ued by th board of health.
Signed-----------------•------------
r) Date
Application Approved By_�_ � 7/�
... ��'
Date
Application Disapproved for the f olio g reasons---------------------•--••--------------•••-••-•---••------•-------------•--......-•----•-------•----•----
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(� �j Date
6S 2.-` VIssued— /
Permit No.---- ----------------------------- .--------------•-------------------•---- � =� .._......
Date
THE COMMONWEALTH OF MASSACHUSETTS
BOARD OF HEALTH
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T.rrftfirtt of TompliFatta
THI.$JS TO CERTIFY, That the Individual Sewage Disposal System constructed (-`I or Repaired ,( )
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by.....-•---- ........ ( ...---•--.---------••--------------•-.
y Ins�jller
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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 N_R: -- ---- 3' ................... dated -.-z_,:..:. ✓ __._....-------------
THE ISSUANCE OF THIS CERTIFICATE SHALL NOTBE STRUE® AS A GUARANTE HAT THE
SYSTEM WILL FUNCTION ATISFACTORY.
DATE---------.. --••----•------------•----•---• Inspec
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