HomeMy WebLinkAboutApp-Permit-ComplianceTHE COMMONWEALTH OF MASSACHUSETTS
BOARD OF HEALTH
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Appliration for 14splo iial. Works Tomtrnrtion Pumit
Application is hereby made for a Permit to Construct (p() or Repair ( ) an Individual Sewage Disposal
System at:
- .. - ......... .............
cation -Address , J �l or Lot No.
.t._..... rn /��.111.S.l .--......
Address
/ �- f' %}—$ /�7� ...........................................
Installer Address
Q Type of Building Size Lot ... 8 7........ Sq. feet
U Dwelling —No. of Bedrooms .............. 3.......................... Expansion Attic ( ) Garbage Grinder ( )
Other —Type T e of Building No. of persons ............................ Showers
� yP g---------------------------- P ( ) —Cafeteria ( )
Other fixtures -------•----------------- ------
< �iYi�®er-r
W Design Flow -------- lZa............................gallons per_ia on per day. Total daily flow ........... -33.p.................... gallons.
WSeptic Tank — Liquid' capacity AMO.gallons Length.. ."'.".r. _ZL Width_ .51F..-_6... Diameter ................ Depth .....
x Disposal Trench — No ..................... Width .................... Total Length .................... Total leaching area .................... sq. ft.
Seepage Pit No ........ /.......... Diameter._ f T_. Depth below inlet... 1`. Total leaching area .... !gks-.11`sq. ft.
Z Other Distribution box (�i ) Dosing tank .��. )
'~ Percolation Test Results Performed by.......�....................................r _.........._._. Date.... Z G _ . `......
Test Pit No. L.`5-Z..minutes per inch Depth of Test .... Depth to ground water ------ ................
(r4 Test Pit No. 2................minutes per inch Depth of Test Pit ............... _.... Depth to ground water ........................
a-----------------------------------------•------•-•--•......----------....._......-----...-•---•-•-• ......................................................
Description of Soil----`�-••�--/- .-- k Y-v� �•c, cry r ...-. ` - ^--- S v rT s 6i 3a /�/ 5`
---... ---------------•-........._..
VC`_'� Tom?! /d? .P1-------.. -25' ..__.. 1. �i P-------- --------------
W
UNature 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
the provisions of TIT1Z 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 by the bard of hea1,t<g&,'2't c
Signed .......... 1 T . ......................... ....1.
Date
Application Approved By...- - C/ � •------•-------------- .� f v
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I-f-6 Date
Application Disapproved for the following reasons--------------------------------------------------------•-------------------------------------•-•------------....
Permit N
......................... .....................
Date
Issued.......................................................
Date
THE COMMONWEALTH OF MASSACHUSETTS
BOARD OF HEALTH
........ .....°:.. GC... OF.... ezj,' ...'.".......................................................
Qlrr,,- - i ..,.�..`oaf Tout Iittnrr
THIS IS TO CERTIFY That the Individual Sewage Disposal System constructed or Repaired ( )
by.... c .. ,rm..-�......... l C� r-: ------------------------------------------------------------ ..----...•....
,r •.....�•••' Ptrstalle ,
at.--------•- ------ --�' i ''./,�r!�P`'1--- ----- ------------------------•---•---•---------------------........--....----
s /' f
has been installed in accordance with the provisions of TI7LE 5 of The State Sanitary Code as described in the
application for Disposal Works Construction Permit No .... ... -"' . ................. dated./:::- ......... /.X .............
THE ISSUANCE OF THIS CERTIFICATE SHALL NOT BE CONSTRUE® AS A GUARANTEE THAT THE
SYSTEM WILL FUNCTION SATISFACTORY.
DATE................................................................................ Inspector