HomeMy WebLinkAboutApp-Permit-Compliance'NOM:_60 .... . Ficic ......
THE COMMONWEALTH OF MASSACHUSE17S
BOARD OF HEALTH
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Appliration for 11ispasal 10.arks Tonstrurtion lbrmit
Application is hereby made for a Permit to Construe
l
System at:
LocationAddress
Ark&: ...............................................
Owner
.10.2-.2caca ...................
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Installer
or Repair (-k) an Individual Sewage Disposal
. .......... . . ........ ..... ... .... . .... ....
... Y02.AALMI Or LL040, ' -AWjA ....................
... 8L!5g AOL,, ................
Address
Type of Building Size Lot ............................. 3q. feet
Dwelling —No. of Bedrooms ............................................Expansion Attic ( ) Garbage Grinder
Other —Type of Building ............................ No. of persons._.....__..____...._........ Showers ( ) — Cafeteria
Otherfixtures ......................................................................................................................................................
Design Flow ............................................gallons per person per day. Total daily flow -------------------------------------------- gallons.
Septic Tank —Liquid capacity ............ gallons Length ................ Width........._...... Diameter......_......... Depth........._.__...
Disposal Trench — No . .................... Width.._........._..__... Total Length................._._ Total leaching area .................... sq. ft.
Seepage Pit No ..................... Diameter .................... Depth below inlet...._._...._........ Total leaching area .................. sq. ft.
Other Distribution box ( ) Dosing tank ( )
Percolation Test Results Performed by .......................................................................... Date..........__..._..................._....
Test Pit No. I ..............:.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...._....._._...._......
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Description of S
.................................................................................................................................................................................................
.......................................................... ..................................................................................... ................. a. i ............... -------
Nature of Repairs or Alterltio s. Answer when applicable.ZAP-154 ..... 1W
....................... .............................................. ............................
Agreement:
The undersigned agrees to install the aforedescribed Individual Sewage Disposal System in accordance with
the provisions of T I T 1L 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.
I A111 T 00
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Sign ... .. ....... "d-1
a;Y
ApplicationApproved By------- - ---- ---------------------------------------------------------------- -------- 7 --- -- ?e ........
Application Disapproved for t ?e4ollog r asons: -------------------------------------------------------------------------------------------------------------- -
Date.......................................................................................................................................... --------------
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Permit No..V760 ...................................... Issued44V4L 9j)2ff ------------------
THE COMMONWEALTH OF MASSACHUSETTS
BOARD OF HEALTH
........ ...................... OF ....... VlArX�k .....................................................
Trrfifirttti of (ompliatta
TO CERTIFY, That the Individual Sewage Disposal System constructed
has been installed in accordance with the provisions of T of The State S
application for Disposal Works Construction Permit Nc07-162-6 ......................
THE ISSUANCE OF THIS CERTIFICATE SHALL NOT BE CONSTRUED
SYSTEWWILLI FUNCTION SATISFACTORY. <—
) or Repaired (-*)
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ITEE THAT THE