HomeMy WebLinkAboutApp-Permit-ComplianceNo ... -298 ............
MI
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THE COMMONWEALTH OF MASSACHUSETTS
BOARD OF HEALTH
0W-j.............. OF ....... ... . +---------1�?r
Appliratinat for Ui ipaa al Works C�.natstrurtion amit
Application is hereby made for a Permit to Construe
System at
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Installer
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t (�) or Repair ( ) an Individual Sewage Disposal
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Address
Address .—
Type of Building _ Size Lot../A%,� __---.Sq. feet
Dwelling —No. of Bedrooms ......... . / ---------------------Expansion ttic ( ) Garbage Grinder (---�
Other — Type of Building ............................ No. of persons...... -------------- Showers ( ) — Cafeteria ( )
Otherfixt res ---------------------------------------------------------------------------------------- -------------------------------•---------------------------
Design Flow .......... �-__-.................-__gallons per person per day. Total daily flow ........... - Z:;� ® ................gallons.
Septic Tank —Liquid capacity< _ '_ allons Length ------ =r!!... Width ---------------- Diameter _______-__- Depth ..... --------
Disposal Trench — No......... ..... Width ....... — ._.. Total Length ------- -- 7: ---- Total leaching area. __-- ._-----sq. ft.
Seepage Pit No .... l9----- Diameter ----- 14------- Depth below inlet ..... 4�.......... Total leaching ar .-P.sq. ft
Other Distribution box (,V,) Dosing tank (--) Ax Am,
Percolation Test Results Performed by ......................... rj................ Date .....
Test Pit No. 1..... e...... minutes per inch Depth of Test Pit..... . ...... Depth to ground water .....
Test Pit No. 2----- �._._._ minutes per inch Depth of Test Pit ----- 1?-�___. Depth to ground water ........................
'/ a �� ........... ,4- - ---- -a--- ------ --- ------------
Description of Soil-----/---..._a-4'�(---- � � �T �-------------- ��-�%4*.----- � ,/��� !��'�
..•------------------------•---- ®---------------------------------------------------+r------------ fi-----------��-----------------•----------s' •-----------
----------------------------------�--------- - --- - ------------------------- ------------------------- ..............................................................
Nature of Repairs or Alterations — Answer when applicable________----..............................................................................
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Agreement:
The undersigned agrees to install the aforedescribed Individual Sewage Disposal System in accordance with
t'1T Ply •-�
the provisions of I LEE 5 of the State Sanitary Code — The uncle, igned further rees not to place the system in
operation until a Certificate of Compliance' ha en issued by the bo-d o i lth.
Sign -......................
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Application Approved BY =-------------------------- 1
Application Disapproved for the following reasons: ---
Date
PermitNo --------------------------------------------------------- Issued --------------- --------
Date
THE COMMONWEALTH OF MASSACHUSETTS
BOARD OF HEALTH
..................... OWN .......... OF ........YARIMIM
k-Erriifiratr of Tout rliFatta
THIS IS TO CERTIFY, That the Individual Sewage Disposal System constructed (X ) or Repaired ( )
by.......................................... DALUZE_....--------------------------------------------------------------------------------............----------------------...----...---
Installer
at ..... LOT ,2... OOD ... D. �-- S. ye-----------------------------------------------e -
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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 No BQIE�.._8...................... dated --------- 1/a/$O___._......_.__....
THE ISSUANCE OF THIS CERTIFICATE SHALT. NOT BE CONSTRUED AS A GUARANTEE THAT THE
SYSTEM WILL FUNCTION SATISFACTORY.
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