HomeMy WebLinkAboutApp-Permit-Compliancei�
(� THE COMMONWEALTH OF MASSACHUSETTSL�
t J30ARD OF HEALTH
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Appltration for Uh4posFal Warks Tonotratrti nt Prrmit
Application is hereby made for a Permit to Construct (�) or Repair ( ) an Individual Sewag e Disposal
System at: 1% M•AS 2- �
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------••-- ....... 94!.5.7 =L•-- ••--•-•-•--•................. �1
Locati - Addressor Lot No
�!_.. v Z.....e--- A&M ik& ----�.. f ZG 7
Owner Address ,alp Z 8V=,
75
Installer Address 770•
Type of Building 1 Size Lot ... Clxrj.G?.�?..... Sq. feet
~ Dwelling — No. of Bedrooms VRIt �1�.__ _. Q__..Expansion Attic ( ) Garbage Grinder ( )
Z' -_l, Other —Type of Building ............................ No. of persons ............................ Showers ( ) —Cafeteria ( )
Other fixtures ............................
W Design Flow .......................... 15.�......... gallons per person per day. Total daily flow ................. 051--dg$-q.............. gallons.
WSeptic Tank — Liquid capacityldggallons Length ... &' 6... Width ...>�_....... Diameter ................ Depth4'.!�.L.._.
x Disposal Trench — No ..................... Width .................... Total Length .................... Total leaching area ------- '_.sq. ft.
Seepage Pit No ------- r------------ Diameter.-_ Z��i___--__ Depth below inlet .... ._4 ......... Total leaching area ..... ;!V.7_._sq. ft.
Other Distribution box ( ) Dosing tank ( )
'~ Percolation Test Results Performed b 4 t--�__._�?'...s..�_�..._/_..._ --I,**' !r._. Date___•$'_-�'.9¢_............
Y t__"'/
,aa Test Pit No i .... minutes per inch Depth of Test Pit.... ._._... Depth to ground water ... y�$__-______-
(i Test Pit No. 2 ................ minutes per inch Depth of Test Pit_ __________________ Depth to round water ........................ t
440
o _r_- '01 .Q7 2- .�'
---
x Description of Soil.-�icfif 2/f".itTy -------------- 7
c — /6 a 4a4ilJ'o�
U ` B`y �6 r� ' f.. �..�i ------------- ---------------
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----------------------- ^/o�Pe�us��. �I/a_�.,�a.�!�zf� a/o���s.�c.d/ow�� � ��'&---'16-���s U
U Nature of Repairs or AlyeratioAnsw r when a pli ble_____________________________________________________________________•______-___----_-•----___.
l�v. k 5.r _-�----•--1.,_ .l_g-------------------------------------------•------------------------------------------------
Agreement:
The undersigned agrees to install the aforedescribed Individual Sewage Disposal System in accordance with
the provisions of 1 t LE 5 of the State Sanitary Code — The undersigned further agree�t-o the system in
operation until a Certificate of Compliance has been issued by the board of h th
Signed. -- . . . •-•--•--• ---- '---------------------
ate
Application Approved By ... -- ......... .L!_----- ----• - ----------------------•-.......... " � .----------
at
Application Disapproved for the following reasons: ................ -••--•-••-••--- -----------------•-•-------------••--•---•--•-------------•------------------
---------•------------------•------•--•---•-----------....--------••---•-------------------------------•- ••----....---••-----•--•-------------------••-•-----••--•-......----------••---••---•-••---.•--
C Date
Permit No ..... Z7 ...`---------------•--------_ Issued -----------rZ---� -�
- ---- -----------
Date
1
THE COMMONWEALTH OF MASSACHUSETTS \
,,,,��-- BOARD OF HEALTH \
............idles ..............OF............. ��.%%1 ................................................
Tntif$rab of Toutpliattrr
THIS IS TO CERTIFY, at the nd:vi al Sewage Disposal System constructed ) or Repaired ( )
�. Z_
by ---------------------------------------------- •--- = ... -------,------------------------------------------------------
Ins
has been installed in accordance with the provisions of TITgI���;'- S T e State Sanitary Co . as desc 'b in the
application. for Disposal Works Construction Permit iV'o...... !_l--- .___.__._____... dated__..______'
-----------------------------
THE ISSUANCE OF THIS CERTIFICATE SHALT. NOT BE CONSTRUE® AS A GUARANTEE THAT THE
SYSTEM WI L FUNCTION SATISFACTORY.
5t...................................................... fDATE.....�------------------ Inspector...
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