HomeMy WebLinkAboutApp-Permit-ComplianceFmc....:.I ..........
THE COMMONWEALTH OF MASSACHUSETTS
_ ,, /BOAR® j%OF` HEALTH
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Appliration for Disposal Works Tomuurtion Famit
Application is hereby made for a Permit to Construct ( or Repair ( ) an Individual Sewage Disposal
S stem at: �! Q
!. .p!XK!. ��....................... 1.�....................................... .
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Locatio Address or Lot No.
y' rnQ. to Y & .T . ,�------.
Owner Address
1.._......
--------------------•----------••••-•-•----------------•-------------------...-•---------------...----------------•-
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Installer Address C
U Type of Building Size Lot____.Z„t.. Z2r'/..Sq. feet
Dwelling —No. of Bedrooms ----------- s3 ............................Expansion Attic ( ) Garbage Grinder (/VP
`4 Other — Type of Building No. of persons ............................ Showers — Cafeteria
a' Other fixtures .......................... .
WDesign Flow --••--_--------•••••-•_..__----J.3-- --- gallons per person per day. Total daily flew ................ 3.3 .............. g. ons;
WSeptic Tank — Liquid capacrtyJaWgallons Length.,5 . Width/,—...A?--- Diameter ................ Depth...>'� _..__.
Disposal Trench — No ................. ... Width -------------------- Total Length .................... Total leaching area .................... sq. ft.
Seepage Pit No ..... !_-__- __--__-• ' meter ..... Q.__..... Depth below inlet._...�:.`.2...._. Total leaching area... ---sq. ft.
Z Other Distribution box ( Dosing tank )
Percolation Test Results Performed by ...... r_ K,.__.L��/Q.'T__._..•......................... Date__'`t .,/-
..................
,aa Test Pit No. 1...A.;/ ...minutes per inch Depth of Test Pit-_ _._ Depth to ground water ..... 'A 47 ....... __.
44 Test Pit No. 2._........ s p
_minuteer inch Depth of Test Pit .................... Depth to ground water ._............_ ....._
O Description of Soil______________A%�11 Q --------- U S.S'l�l---�,----- ..� ._-.../l�o�•-------�� _� / ..._.. ,l�lU/zi�
,��,.....-•---•------•-•-••-------•-------•--.. iQl ado------------------�' ......f.G% !.1. l _.__*Z:;t lrejelU
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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 TIT 1Z- 5 of the State Sanitary Code — The undersigned furtherragreest to place the system in
operation until a Certificate of Complianc been d th ar ealth.Si ed-- ----- ---- -- - - ------•..........................
Date
Application Approved By. ------ ---------
Date
Application Disapproved for the following reasons__________________________________________________________________________ ................. ......---
______
...................
Date
Permit No Ze ., ------------------------------ Issued ------.s �'.- .....................
Date
THE COMMONWEALTH OF MASSACHUSETTS
BOARD OF HEALTH
- ............. o `�...............................-----•--
Trrfifirate of Tomptianrr
THIS IS TO CEUI TIFY, That the Individual Sewage Disposal System constructed (r Repaired ( )
1-- .-- f, --s
Installer71._;at---------- �11'---•-----------•-----�-.I--------- --------- --------------------------------------------------------------------
has been installed in accordance with the provisions of TITIN 5 of The State Sanitary Code as described in the
application for Disposal Works Construction Permit No.�hr.-2:.::r�lt-�.................... dated_-- T_:>5: ....................
THE ISSUANCE OF TSATISFACTORY.
HIS CERTIFICATE SHALL NOT BE CONSTRUED AS A GUARANTEE THAT THE
SYSTEM WILL FUNCTION
DATE ------------2=25;; -=:?-
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