HomeMy WebLinkAboutApp-Permit-ComplianceNo.10 ! y FEB./Jf ...
THE COMMONWEALTH OF MASSACHUSETTS
BOARD OF HEALTH 1
L
Appliration for Dispnsttl Works Tonstrudiun 1rrutit
Application is hereby made for a Permit to Construct ( ) or Repair (LKan Individual Sewage Disposal
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33
t
Location
..- - -------•-`---..-/- U-
......Loca ion - Address rt No.
1.. .......... .. -•---
-....................-----------------......................•--...._._._...-•--• -
Owner (� Address
p� Installer Address
6 Type of Building Size Lot ............................ Sq. feet
aDwelling —No. of Bedrooms ........................ ................Expansion Attic ( ) Garbage Grinder ( )
04 Other — Type of Building _ -..__•____________________ o. of persons ............................ Showers ( ) —Cafeteria ( )
a Other fixtures ...............
W Design Flow ................................ .......... er person per day. Total daily flow ............................................ gallons.
W Septic Tank —Liquid' capacity .___.__.... allons
Leng
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Width ................ Diameter ................ Depth ................
x Disposal Trench — No .............. ...... idth...._............. Total Length .................... Total leaching area ................... sq. ft.
Seepage Pit No -_---------_----- Di mete ........._....._._._ Depth below inlet .................... Total leaching area .................. sq. ft.
Z Other Distribution box ( ) Dosing to ( )
14 Percolation Test Results Pe med by----••......•-•.......................................................... Date ........................................
14
1.4 Test Pit No. 1................minutes per inch Depth of Test Pit .................... Depth to ground water ........................
fi Test Pit No. 2................minutes per inch Depth of Test Pit .................... Depth to ground water ........................
04 --- --------------------------------------
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•--------------------•-------------•-----•--•----------------
0 Description of Soil -----------------------------------------------•-----•----------•------------...------...--.----•-------•------••--•----•--......_...-------•-------•---•-•-----------•-
U--------------------------------I
-1 -_..----------------
•................
U Nature of Repairs or Alterations —Answer when applicable_._.__ +- - y� ... _ .. `�l U1V�,.•.........................
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Agreement: V
The undersigned agrees to install the aforedescribed Individual Sewage Disposal System in accordance with
the provisions of TITL iE 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 boar of health.
Signe" ^ dG.... ..........-
Date _
Application Approved By ...................................................................................... -a
L
Date
Application Disapproved for the fol wing real ns:•-•-•--••-•--•-••-•------.....••-----------•-----•-•------••-•--•••----.....•••----•....._•••--•...--•-•--•-_...
PermitNo ........ ........................................... Issued_ ..................... .... ......
ate ..........
THE COMMONWEALTH OF MASSACHUSETTS
WLT (4Rp
5 ` BOARD OF HEALTH
OF........L. ./).............................................. `
htrdifiratr Of Toutplinurr
THIS IS TO CER , That -the I�Pvi Sewage Disposal System constructed ( ) or Repaired
by---------- ---------------------------------- -------- �• I
ns
/ J l.._ /g�
has been installed in accordance with the provisions of r of The State
application for Disposal Works Construction Permit No-_____ _V_-Q�_____________________
THE ISSUANCE OF THIS CERTIFICATE SHALL NOT BE CONSTRUED
SYSTEMA ILL- �U�NCT)QN SATISFACTORY. C ---
DAT - r ... InsP�ty - , l CPs'�C
.....
.....................
-•------'m the.
�V.,
THAT THE