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HomeMy WebLinkAboutApp-Permit-ComplianceF)6jAJ0eP_ ID Jeri THE COMMONWEALTH OF MASSACHUSETTS _ BOARD OF HEALTH ............../ 4C .......... OF ....... _.... .r��%Q......................................... Appliratiun for Disposal Works Tons rur#iun jrrmit Application is hereby made for a Permit to Construct (k) or Repair ( ) an Individual Sewage Disposal System at: LJ — 'N���.............................................. ---- T � NR P / a .---. ---- Location - Address or Lot No. ........ -Thomas.I'-DwPaza......................................................... ,........ ...................... ...................... Owner Address a ..Gsar..DaaJnc...--•---------------- Installer Address Type of Building Size Lot ..... ..&6_6...... Sq. feet Dwelling —No. of Bedrooms .......... Z ............................Expansion Attic ( ) Garbage Grinder ( ) i Other — Type of Building ............................ No. of persons ............................ Showers ( ) — Cafeteria ( ) Otherfixtures.-----------•-•------------------------•------------•-----•----------------••-----------------•-------•---•-----•-----•-.-------•-------•----------- Design Flow............................................gallons per person per day. Total daily flow.. -_........___..._.._......._..._...._...gallons. �� Zz© jSeptic Tank— Liquid' capacity.?�2 ..gallons Length .... 8-------- Width.... .____.__ Diameter ................ Depth._ 4......... Disposal Trench — No..... . ............. Width .... la .......... Total Length... Z_Z._...... Total leaching area ..Q0-5....... sq-.4t. Seepage Pit No ..................... Diameter .................... Depth below inlet.................... Total leaching area .................. sq. ft. Other Distribution box (X) Dosing tank ( ) Percolation Test Results Performed b ......u�.__....�?z� �1U� . y ....- --- .. _.. - �-------•----=---•----- Date.----- -----•-- ---• ............... �j Test Pit No. 1--- ..minutes per inch Depth of Test Pit ..... L'�o��.--.. Depth to ground water ..... ��`?®..`........ 4 Test Pit No. 2................minutes per inch Depth of Test Pit .................... Depth to ground water ........................ ..... Description of Soil - �-.-- ' ...... ---•--....................................................- . --- .... -----. --- - --------------- --_. -------•---••...........................................................................................................•----•--......•_.... 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 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 issued by the board of health. Application Approved Application Disapproved for the following • 11 14�86_„___•__ pate ----------- Date Date Permit No ........ 8fz..06 ............................... Issu - - -- D �%Lp ....... jF S THE COMMONWEALTH OF MASSACHUSETTS BOARD OF HEALTH Q!YN......................... OF...................... .ARINIO.UTIi.................................. (arrftfutt#r of (omptia"r THIS IS TO CERTIFY, That the Individual Sewage Disposal System constructed (X or Repaired by.....�'i_ar..11am,.Ins---.................................................................. Installer at. .... Lat_.- --------------------------------•-•-- has been installed in accordance with the provisions of TITLB ,5 f The State Sanitary application for Disposal Works Construction Permit No ....... &6=.L�'� "k...........•.... dated./ THE ISSUANCE OF THIS CERTIFICATE SHALL NOT BE CONSTRUED AS 4A SYSTE ILL/,iFUNC`TI.......................................... SATISFACTORY. - - IMP�-X�� described in the EE THAT THE