HomeMy WebLinkAboutApp-Permit-Compliance2,6
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THE COMMONWEALTH OF MASSACHUSETTS
BOARD OF HEALTH
0 F_., KI.V OCJ, .-------------------------------------------
Appliration for Bigpaoal Works Towitrurtion ramit
Application is hereby made for a Permit to Construct ( '-�or Repair ( ) an Individual Sewage Disposal
System at: 9 3
............ .................Zap---_---_------------------............................ ......... A)q. )
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Addressoc or Lot No.
... .................... <
. ............................
.........
ner ..... ..... 'X�dress 4A
............................ ..................................................................................................
Installer Address
Type of Building Size Lot.A/4;? 70'..Sq. feet
U Dwelling —No. of Bedrooms ............... S
.............. ............. Expansion Attic Garbage Grinder (
Other—Type of Building ...... ..................... No. of persons ............................ Showers Cafeteria (
Otherfi tures ......................... ............................................................................................................................
Design Flow ......... Zn -_3 ....................... gallons per person per day. Total daily Cow ----------- :5-3.5-P ...............gallons.
P4 Septic Tank—Liquid capacity/C2UWlons Length... e_ Width._.'f`___`-.. Diameter......__.___.._. Depth_!K__.57_..'
Disposal Trench — No- -------------------- Width.._........_..._.... Total Length.................._ Total leaching area .................... sq. ft.
Seepage Pit No ...... / --------- D eter.,%CV ......... Depth below inlet ....... --- Total leaching area .... 322_sq. ft.
Z Other Distribution box ( /—r Dosing tank (_ )
Percolation Test Results Performed by....7................ Date... ........
Test Pit No. I ..... !<:��ninutes per inch Depth of Test Pit.../ 05:2._. Depth to ground water. -,/r .. ..............
Test Pit No. 2 ................minutes per inch Depth of Test Pit____._.......___.... Depth to ground water.__......_.........._.._
........... W ................................................................... .......... ............................................
Description of Soil ... ? "r- —
. ..... .. ......... A/_<� 0
.......... -.e ........ K . ..... (
. .........
- ;EP
(74- - -- _---------------- 7 ------------------------------------------ -----
..... RQP ...... (aa . �.; a- . ........ ------------------------
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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 TITLE 5 of the State Sanitary Code — The undersigned further agrees not to place the system in
operation until a Certificate of Compliance has be i4uedy tboard of health.
Signed... ................... .......................................................... ................................
Date
ApplicationApproved By_._ --- ..... .. ........ ---- -- -- -- - ---- - ------------------------- ........... Q - -----
Date
Application Disapproved for the follo ng reasons: ................. ............................................................................... -------------
Permit .......................
......................................
Date
Issued------- (_ i9i--------------
Date ..............Date
THE COMMONWEALTH OF MASSACHUSETTS
BOARD OF HEALTH
.................... .....................................
Tntifiritr of Tompliana
THIS IS TO CERTIFY, That the Individual Sewage Disposal System constructed (--ror Repaired
by....... . ..........................................................................................................................................................
Installer
-,.:.=--........ ------------------------------------ .....................................................................
at ....... . ..... .. . ....... 6� �..
has been installed in accordance with the provisions of TITLE 5 of The State Sanitary Code as described in the
application for Disposal Works Construction Permit No.-_- — ----- ---------- V...._... dated ----- :__) ........ & .. . ............
THE ISSUANCE OF THIS CERTIFICATE SHALL NO C STRIKE® A GUARANTEE AT THE
SYSTEM WILL FUNCTION SATISFACTORY. 77
DATE.-------- ? . . ..... ......................... Inspec ... .... ;c.: ... ....... 4...- ----- --- -.------------------•----•---•---