HomeMy WebLinkAboutApp-Permit-Compliancev... F�s........s.............
THE COMMONWEALTH OF MASSACHUSETTS
BOARD OF HEALTH
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Appliratiou for Dismial Works Cnontitrur#iun Prrutit
Application is hereby made for a Permit to Construct 06 or Repair ( ) an Individual Sewage Disposal
System at: r. /PiJ1p(/7Y1
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.......... p� - or Lot No.
_ i n nn g n 12 Lam`() JQ ✓1� Address �' � [ f � _03jOF� /� (/�• i�Ol2TH A
Installer
Address
...........................
-t
Type of Building Size Lot.-Z �. 8 �b --`-" Sq• feet
Expansion Attic Garbage Grinder ( )
Dwelling —No. of Bedrooms-------------•--•--------------•----------- Ex ( ) -
Other — Type of Building ----_-----.---•---.-.-•--. No. of persons ............................ Showers ( ) — Cafeteria ( )
Otherfixtures -----•------- --•---------------------------•-------------•----------
Design Flow ............................. ..`�_.-._..gallons per person per day. Total dAil flow --_-------•••---------- � � -- ..--grallons .
Septic Ta Liquid' capacity�OD �_.-gallons Length.. �.(o.`! _. Width% gore. Diameter-_.-•-_•••__---• Depth 4 4..._..
Disposal �c(i— No. ...... I------------ Width .... %b.......... Total Length._ —9.......... Total leaching area..._.._sq. ft.
Seepage Pit No ..................... Diameter .................... Depth below inlet................... Total leaching area ------------------ sq. ft.
Other Distribution box (>O Dosin tank J
Percolation Test Results . Performed b ''_.R.. (,( ,5'F/Q p�LL� /J•a Date_. A!��`--- J978
Test Pit No. 1ZX51_2,. minutes per inch Depth of Test Pit ....... .4.._.... Depth to ground water... 64'...........
Test Pit No. 2---------------- minutes per inch Depth of Test Pit .................... Depth to ground water ........................
... • -- .....--•-•--••-----------------•-----•--• ---
Description of Soil �'d1�!�l'----Di(JJ'1.!�lb 1�91!/�L :�..�' �..
......................................... ---------------------------------------•----
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
the provisions of TIT?,;,;. 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 board of health.
ed. ---
Application Approved By-•----------•--------------------•--------••--•-•--.-----
------•.••--------------
.l-?c-...----•-.....--•......
Date
Application Disapproved for the following reasons__________________________________________________________________
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..-•-------•--...---•---•---•-••-----•---...------••---•---•-----•--•-• -- .................................... Date
Issued--------------------------------------------------------
PermitNo --------------------------------------------------------- Date
THE COMMONWEALTH OF MASSACHUSETTS
BOARD OF HEALTH
.......................................... OF .....................................................................................
Tntifirtttr of Tuawfianrr
THIS IS TO CERTIFY, That the. Individual Sewage Disposal System constructed ( ) or Repaired ( )
by-----------------------------------------------------------------------------------------------------
Installer
at............................................................................................................................................................................................... ------
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 ......................................... dated___.___.____._.___..._......_...................
THE ISSUANCE OF THIS CERTIFICATE SHALL NOT BE CONSTRUE® AS A GUARANTEE THAT THE
SYSTEM WILL FUNCTION SATISFACTORY.
DATE.....................•---•--•-•----...................-•--••----•-••-•---•--•-•. Inspector