HomeMy WebLinkAboutApp-Permit-ComplianceNS!�._�S_y
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4'-1'jRjf Vdb�f�t6�MrEti�iIW-�'MASSACHUSETTS
BOARD OF HEALTH
-TO .............. OF ......... )_Aem .. ac).77-1 .......................................
Appliratiou fur Bi!ipviial Workii Tilmitrurtivu Urnuit
Application is hereby made for a Permit to Construct V,) or Repair an Individual Sewage Disposal
System at: Map 99 LV-r-� 03 P9 i Z3
�P/(o ........ ....... )eV_i ----- ------------------ w ---------- i ------------------------------ ------- - --------------------- 7 --------------- - 6� -------
Location - Address or Lot NO.
- ----------------- -7-------------------------------- ------- - --- ------------------------------------------------------------------------------------- - -----------
Address
---------------
........................ --- ------------------------------------ --------------------------------------------------------------------------------------------------
Installer Address
t .... /7j._75�_Sq. feet
Type of Building Size Lo -_
U Dwelling — No. of Bedrooms ......... ------------------------------- Expansion Attic Garbage Grinder (
P4 Other—Type of Building ............................ No. of persons ---------------------------- Showers Cafeteria (
PA Other fixtures ------------------------------
W
------------------------------------------------------------------------------------------
Design Flow _------------0--_-----------------gallons.
..;? _----------------------- gallons per person per day. Total daily flow -----------
Septic Tank—Liquid capacity/8®'4?--gallons Length .... 0 . . ..... . Width ...... 4_� ---- Diameter________________ Depth ..... 4 .......
Disposal Trench — No. -------------------- Width .................... Total Length_-_-_-__-_---___-- Total leaching area ---_----_--------- sq. ft.
Seepage Pit No -------- I .......... Diameter-__- Depth below inlet ....... 6 ---------- Total leaching area..-5_8..,,.4sq. ft.
Other Distribution box (k) Dosing tank
Percolation Test Results Performed by ------ L (2 ------- ....... Date_.. . ...........
Test Pit No. 1....C- __.minutes per inch Depth of Test Pit__j..4_ --- 4- -1! ..... Depth to ground water.A�V..-r_.�—
Test Pit No. 2 --_----------- minutes per inch Depth of Test Pit --------_--------- Depth to ground water._.___..._____._____....
............
ater------------------------
............ --------------------------------------------------------------------------------------- --------------------------------------------------------
0 Description of Soil ------- ----------------
.... g ---------- 1�L_.,4.63 ---------------------------------------------------------------------- .................................
--------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------
------------------------------------------------------------------------------------------------------------------------------------------- ------------------- ........................................
Nature of Repairs or Alterations—Answer when applicable ------------------------------------------------------------------------------------------------
--------------------------------------------------------------------------------------------------------------------------------------------------------------------- ----------------------------------
Agreement:
The undersigned agrees to install the aforedescribed Individ wage Disposal Sy-
stem in accordance with
the provisions of TITLE 5 of the State Sanitary ode The utdersi f 6
I � g9A further agrees not to place the system in
operation until a Certificate of Compliance has b en 1 d byAfF(�\bokr(�of health. —�F
..... -7- ..............
igned ..... - - - ----- ----------- - - - — --r
----C ------------------
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--- --------- ----------------------------------------- .......
Application Approved B - ---- ----- ----- -- -
BY- Date
, 1, z n n . . ............
Application Disapproved for the followin asons: ----------------------------------------------------------------------------------------------------------------
------------------------------------------------------------------- - ---------------------------------- I ------------------------------------------------ t --- 0 ----------- -------------------- ----------
Dat
---------------
Date
Permit No ------ q Issued ------- --- ---- - --- ----
.......... ___-QJ ---------------------- -
THE COMMONWEALTH OF MASSACHUSETTS
BOARD OF HEALTH
7 ........ OF .......... ............. ................... ................. * ....... * ----------
THIS IS TO CERTIFY, That the Individual Sewage Disposal System constructed or Repaired
by......................... "I ............. I ...... --------------------------------------------------------------------------------------------------------------------------------------------
Installer
at-_. _ ------ -------- ------------- -------- ----------------------------- ---- ---------------------------------------------------------------------------
i / T
ig accof ith the1P//C(,,ls'16
tall e4 it
has been ins he State Sanitary Code as described in the
application for Disposal Works Construction Permit No ---------
dated__.._-___..
..... ----------
-
THE ISSUANCE OF THIS CERTIFICATE SI- T-STRUED AS A 6 THE
SYSTEM WILL FUNCTION SATISFACTORY. /%
--- .. .......
DATE--------- =-------------------------- Inspector_ ..........................