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HomeMy WebLinkAboutApp-Permit-ComplianceTHE COMMONWEALTH OF MASSACHUSETTS BOARD OF HEALTH .......................................... MOF ..... q Rm . v UrN--•----------------------------•-----•-•--------... Appliration for Dispnoal 18orks Tonstrurtiun ramijt Application is hereby made for a Permit to Construct or Repair ( } an Individual Sewage Disposal System at: ....................................... - Lo Lo tior. -Address or Lot No. ............... . pmjm..•-90 s, �' ��...........- �3 o x /.2 73 W E.rr DE�wi 1!q............. . . ............. ..•••••...---..........--••--•••----••..... � 'owner Address ey?..._.....1_. J?L!---•---•...........-••---••..................•-•--._..1./.GGi^�r/�... ............... Installer Address Type of Building 3 Size Lot .../....r..7....7 ...............Sq. feet Dwelling — No. of Bedrooms............................................Expansion Attic ( ) Garbage Grinder ( ) Other —Type of Building ............................ No. of persons ............................ Showers ( ) — Cafeteria ( ) Other fixtures---------------------------------•---......•---...........:. Design Flow ........................S .......... gallons per person per day. Total daily flow .......................... . ........__ lons. Septic Tank — Liquid capacity)000 --- gallons Length..$ !:k".. Widthit:L4'f._. Diameter ................ Depth-.'-:-!!!... Disposal Trench — No ..................... Width .................... Total Length .................... Total leaching area .................... sq. ft. Seepage Pit No ....... )............ Diameter..G...f?...... Depth below inlet .... 1.4............. Total leaching area.-2.�. .....sq. ft. Other Distribution box (X) Dosing tank ( ) / Percolation Test Results Performed by...S.w E!r.......................................... Date ...4-1-B .................. Test Pit No. 1 I ess 2- minutes per inch Depth of Test Pit.. .iM G."._-._ Depth to ground water..tVA... Y)!'%y Test Pit No. 2................minutes per inch Depth of Test Pit .................... Depth to ground water........................ .. ...._.. .....•... ..----•••••................................... ... .................................................. Description of Soil ....... l.U.�r�''Iu..._FlI�E...S)4.4" ....... 4VV C..6�JN V,Ee2.!_hLc��✓�__Sl9d/�-.......•.............. _-.- : ............................................... -------------•-••---------•-- --•--...----------•---•---------------•-------------................------....-----------------....------••-----•--------•-------•----------..._..........---..........--- 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 TITLL 5 of the State Sanitary Code — The undersigned further agrees not to place the system in operation until a Certificate of Compliance has been issued be boar�h....................... .. ... �y...... Signed. ._. Application Approved By_ ................. } .._.. : l .................•...................---••-......................_.... Date Application Disapproved for the following reasons: .................. ._.....___._ ---------------------------------------------------------------------------------------------------------.-•---•---------•-••----•-••--•---------•-•-•-•-------•--.....--••-•--•---.........•..... ?? n Date Permit No .... 2�_. d.._.1._...................... Issued_ ............................... Date THE COMMONWEALTH OF MASSACHUSETTS BOARD OF HEALTH . .................. tr,,�/�,,� OF...,.�1,i:%,?�s/..... .............................................. Trrtifirer of Tontplianrr THIS IS TO CERTIFY, That the Individual Sewage Disposal System constructed (, or Repaired ( ) / Inata.... ------------------ »----------------- ..------------ ller at..... % J f?'....... /l j== r s%rs S-._...� y, .........-•-----•............................................................................._......_ has been installed in accordance with the provisions/bf TITLE 5 of The State Sanitary Code as described in the application for Disposal Works Construction Permit No..fl...3-- ..............• dated.... .................. THE ISSUANCE OF THIS CERTIFICATE SHALL NOT BE C TR AS A GUARANTEE AT THE SYSTEM WILL FUNCTION SATISFACTORY. DATE...................�......... ._ � �� ........_... •- - -- Insp tor.. - ........