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HomeMy WebLinkAboutApp-Permit-ComplianceNo/:. F� ......�..�... d THE COMMONWEALTH OF MASSACHUSETTS BOARD OF HEALTH 1..Q.Gc!/,_3 ................. OF ......... .Y1!1.0..slT(......................................... Alipiirtt#ion for Disposal Warks Tonstrnr#iun 1hrmit Application is hereby made for a Permit to Construct ( ) or Repair ( ) an Individual Sewage Disposal System at: n../ 9 _. D ....................... .............. -T:-- . � Z............------....2 -..•--•--� Location -Addressor Lot No. Address ----------------- -- •._ • .-_--.----•----.. --- •------ - ... -•-•-------' ......................... 1 Owne ---•-------•---•-•--..-----•-------------•..•-----------.....--•-•.------------••..............---...------------•----•---------' Installer Address Type of Building Size Lot --- f_rQ 3�Sq. feet U Dwelling — No. of Bedrooms ............3 ...........................Expansion Attic ( ) Garbage Grinder ( ) A4 Other —Type of Building _-----------•-_--_---- No. of persons ............................ Showers ( ) — Cafeteria ( ) Pa Other fixtures ---------------------------------- j%ZO/7'--------------------------------------------------------------------------•------------- Design Flow .......... 114........................gallons perp�per�day. Total daily flow .............. 33 -I? ---•---_------_-gallons. WSeptic Tank —Liquid* capacity./.44 _gallons Length..,1.'.6." Width...¢'Z.0 "r Diameter ................ Depth.--- ,_ ¢" x Disposal Trench — No ..................... Width .................... Total Length .................... Total leaching area .................... sq. ft. Seepage Pit No ......... ,l........ Diameter. --/O./....... Depth below inlet ..... Total leaching area ... Z,6,..7 ... sq. ft. Z Other Distribution box ( ) Dosing tank ( ) Percolation Test Results Performed by --------- 1-0? cJ.... O."X/reAliziU...ZQ.C... Date ......... �' 1.� .... ,aa Test Pit No. 1.G. ....minutes per inch Depth of Test Pit../SEO....... Depth to ground water ........................ (i Test Pit No...2................minutes per inch Depth of Test Pit .................... Depth to ground water ........................ ------------------------------------- •--•---------•-------------..... *..........--------------------------------------------------------------- ---------- ODescription of Soil ....... 0-------TI�P_.r� __ril. 's.0Z..--------•-----------------------------------------------------------------------------•----- V--------------------------------- --/ s------ ------ W----------------------------------------------•--•-----•----•••---•----•----------•--------•-••----......... -•--••-------••---------•-------•--••-------------•-•---------•---•--•----•---------..--- UNature 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 TI "12 5 of the State Sanitary Code. — The undersigned further agrees not to place the system in operation until a Certificate of Compliance has beengs e"y #iV boafZ�f health. .--------------» -, -�._ . --............ ---.•-•-- -•••--•---••---'-•.•- D to Application Approved By...------ ---•-- ...... -1, 0--- / ate Application Disapproved for the following reasons: --------•------------------•------------------- -------------------------------------------------------------------------------------------------•------...--------------•---------•----•--- ............................................................ Date PermitNo ......................................................... Issued ....................................................... Date THE COMMONWEALTH OF MASSACHUSETTS BOARD OF HEALTH ........................................... OF ..................................................................................... :,' �rr#i�irtt#r laf �lant�iittnrr THIS ISS' CE RY,That t dividual Sewage Disposal System constructed) or Repaired ( ) by r (-.:..... ...................................... --•---•-....'-----...........-'---•-'---•---...--••--.._.....---•-••-----. Installer at----- t cite' -------- -- �.....-----------------1-- ......-------------------------------------------------- d it1 accordance with the rovisions of TIT /5 of Th State Sanitary Co 's de/cribed in the has been instalie application for Disposal Works Construction Permit No ....... .......... dated ......... // ................. THE ISSUANCE OF THIS CERTIFICATE SHALL NOT BE STRUED ASA G ARA1dTEE AT THE SYSTEM WILL FU CTIO SATISFACTORY. nATF. S� // /111 Tncnrrtnr .moi 1s --