HomeMy WebLinkAboutApp-Permit-ComplianceNo: ...... 8.3.-.a22..F�s.....15. 0 0
THE COMMONWEALTH OF MASSACHUSETTS
BOARD OF HEALTH
.................... TOYIN........ OF ......... ARMOUTH....
Appliration for Disposal Works Tonstrurtiun rrrmit
Application is hereby made for a Permit to Construe
System at •
oca ion - Address
................-----------.'.. _�..---------------------------------------------
.. - ....
77��a�7 p7 O ner
...................................................................
Installer Address
Size Lot ............................ Sq. feet
........................Expansion Attic ( ) Garbage Grinder ( )
..... No. of persons ............................ Showers ( ) — Cafeteria ( )
t ( ) or Repair ( g) an Individual Sewage Disposal
5- )--bT-JI2, miqp-s3
or Lot No.
Address
Type of Building
Dwelling —No. of Bedrooms
Other — Type of Building ...
Other fixtures
....
Design Flow............................................gallons per person per day. Total daily flow ............................................ gallons.
Septic Tank —Liquid capacity ............ gallons Length ................ Width .... _........... Diameter ................ Depth ................
Disposal Trench — No ..................... Width .................... Total Length .................... Total leaching area .................... sq. ft.
Seepage Pit No ..................... Diameter.................... Depth below inlet.................... Total leaching area .................. sq. ft.
Other Distribution box ( ) Dosing tank ( )
Percolation Test Results Performed bY.......................................................................... Date ........................................
Test Pit No. 1 ................ Qnutes 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 ........................
Descriptionof Soil..............•---.......-------•---....-------------------------------•---•--•-------------------------------------•------------------.........------------------------
. ... ..... . .... 0 .......
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Nature of Repairs or Alterations —Answer when applicable..... lT/._.'._ ._l.% ..............
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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 u\d by the board of health.
--------------- -------8.1251-83 -----
....:........ ...... `
Application Approved BY. - a �.r .
Date
Application Disapproved for the f olio ing reasons:-•-------------------------•----••----------•------•----------•---------------------------------------•--•...---
Permit No ------- aa ---2 22 ........................
....................................................................
Date
Issued _ __ ..............
Date
THE COMMONWEALTH OF MASSACHUSETTS
BOARD OF HEALTH
................ OWN.............. OF.......... 7 TJT i............................-•---................
Tntifirab ,af Toutpliatta
THIS IS TO CERTIFY, That the Individual Sewage Disposal System constructed ( ) or Repaired )
by-••---KBHj.... 1NC-•............................................................ ----------•--------------............................................................................
_ Installer
at..--------- Lf ---- = = = %%j? ='' = - --•----•------------•----------•-----------------•-----...--------------•-------------------•---------------
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 No --- 8.3.-372..................... dated ---- .$/25/.$-3.._................._...
THE ISSUANCE OF THIS CERTIFICATE SHALL NOT NSTRUE® AS A GUARANTEE AT THE
SYSTEM WILL FUNCTION SATISFACTORY.
DATE..... �� ......................... InsP -- .....
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