HomeMy WebLinkAboutApp-Permit-ComplianceNa- - Fim ............... ...............
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THE COMMONWEALTH OF MASSACHUSETTS
BOARD OF HEALTH
A......... OF ........... >.".A ... tn- - ...j --- z--k.k . .............................
for Elisvoiial Works Tongtrurtion Prrmit
Application is hereby made for a Permit to Construct ()C) or Repair an Individual Sewage Disposal
System at: ) ey)F)p
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Location - Address or Lot No.
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Installer AddrN -2
Size t-.Iq ...................Sq.1feet
Type of Building .
Dwelling —No. of Bedrooms._.._._. 3...............................Expansion Attic Garbage Grinder
Other —Type of Building ............................ No. of persons ---------_------------_--- Showers Cafeteria
P4Other fixtures ------------_-_--------- ------ ............................ .............................................................
Design Flow ...... k1Q0 ..............................gallons per person per day. Total daily flow _-__ :3.3-4.0 .................... gallons.
1:4 Septic Tank — Liquid'capacity.Bd Mons Width..<A_1bDiameter ................ Depth .... 5.7 .. 4.
Disposal Trench — No. ..A ............ Width .................... Total Length.._._..._....._.._.. Total leaching area ... --_------------ sq. ft.
Seepage Pit No --------- I ........... Diameter..... ....... Depth below inlet ...... q . . ........ Total leaching area .................. sq. ft.
Other Distribution box Dosing tank(
%X�f�h ... .. !�� ....... I.J.-n-.".Q. Date ........ .............
Percolation Test Results Performed by ..... e ... i>An
Test Pit No. 1_412 ..... minutes per inch Depth of Test Pit ... ....... Depth to ground water .........................
Test Pit No. 2 ................ minutes per inch Depth of Test Pit .................... Depth to ground water.._......._.._...._..__.
P4.................................................................................................... .........................................................
0 Description of Soil ----- n --- — --- 3-2 ---------- T_Cxi? .. F . ..... . ....................................................................................
u�;
........ 52 .. . ... e_!� ----- i, ------- Sat'-: X�t ----- ---- Mi. --r :Ee-9,2 -----
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U 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 TILT IL 5 of the State Sanitary Code — The undersigned further agrees not to place the system in
operation until a Certificate of Compliance has been iss ed by the b oa!o of health.
Signed.... ... gned .. ... .......................... .... .. ... . ....
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Application Approved By ..................... . . ... . .......... . .... ---------
Application Disapproved for the following reasons: ................................................................................................................
........................................................................................................................................................................................ ................
Date
Permit No.....__ J.23 ............................ Issued ............... fZd- -ID/P .................
THE COMMONWEALTH OF MASSACHUSETTS
BOARD OF HEALTH
.......................................... OF .....................................................................................
Tntifirair of TI-Imptiatta
THIS IS TO CERTIFY, That the Inoividual Sewage Disposal System constructed-kk- ) or Repaired
by ------------------------------------------------------------ < ......
...................... .........................................................................
Ir;staller
7'
at--------------------------------- --------------------------------------- ............ -------- ( .............. . .................................................
has been installed in accordance with the provisions of Tj '.1 LE 5 of The State Sanitary C�de. as/described in the
L
application for Disposal Works Construction Permit No ...................... dated...-. .....................
THE ISSUANCE OF THIS CERTIFICATE SHALL NOT B STRUED AS A GUARANTEE T / THE
SYSTEM WILL FUNCTION SATISFACTORY.
Z aj�
DATE.....----- _42Zw ............................... Insp or ... .. .... ..........................
- P• tfi &A AT TZJ P = A A ACC A e^LJ I 1C='r"rC