HomeMy WebLinkAboutApp-Permit-ComplianceN011. 53._ Fxs % ._........._
THE COMMONWEALTH OF MASSACHUSETTS
BOARD F HEALTH t
jOW�.........................OF....... �I...M.14.M.147# ......................................................
A.P. iratiun fur 31iupuual Works Tonstrnrtiun 1hrmit
Application is hereby made for a Permit to Construct
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Locati n -Address
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((JJ ��Onwner
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Installer
) or Repair ( ) an Individual Sewage Disposal
or No.
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Add� s
Type of BuildingSize Lot ............................ Sq. feet
Dwelling —No. of Bedrooms-------^Z-------------------------------Expansion Attic ( ) Garbage Grinder ( )
Other — Type of Building ---------------------------- No. of persons ............................ Showers ( ) — Cafeteria ( )
Otherfixtures------------------------------•-----•--------•--------.....---...----...............--------••-------------........---.........----------•-....._._...
Design Flow ..... !LQ ................................gallons per person per day. Total daily flow ............................................ gallons.
Septic Tank — Liquid'ca.pacityiPA0_gallons Length ................ Width ................ Diameter ................ Depth ................
Disposal Trench — No ..................... Width... ._.............. Total Length .......... Total leaching area .................... sq. ft.
Seepage Pit No ..... 1 .............. Diameter --- /C2........... Depth below inlet --- Ll.............
Total leaching area .................. sq. ft.
Other Distribution box ( ) Dosing tank ( )
Percolation Test Results Performed by .......................................................................... Date ........................................
Test Pit No. 1................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 ........................
Description of Soil P��..i. �.�................ �_..... --•-------=......................
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Nature of Repairs or Alteratigns — An�wer hel
Agreement: 1 vt
The undersigned agrees to install the afor
the provisions of TITIE 5 of the State Sanitary
operation until a Certificate of Compliance has be
Application Approved By ........ 1)
Application Disapproved for the
Permit NoA-aS':.
Disposal System in accordance with
ier agrees not to place tl a system in
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Issu -
-- . 51 `_!.o 9 Date .............
Date
Q(`1 Or ('1AD THE COMMONWEALTH OF MASSACHUSETTS
BOARD OF HEALTH
w.......................... OF... II M 21YT f.........................----........................
(Inxtifiratr of Tomptiunrr
HIS TO CERTIFY, That the Individual Sewage Disposal System constructed ( ) or Repaired (�()
by E3......._E
Installer
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••••--------------------
�I
at... tl ll01t1 �aP K.... � � _ £IT !� --f 4 ......................•....---------------------------•--.....-----------.............................
has been installed in accordance with the provisions of TIS^� of The State Sanitary ode as ` sc ' 'n the
application for Disposal Works Construction Permit No d ?. ................... date ..........✓}. __.__.....
THE ISSUANCE OF THIS CERTIFICATE SHALL NOT BE CONSTRUED AS NTEE THAT THE
SYSTEM 1NILL FUNCTION SATISFACTORY.
DAT1 . . -.- ).-R.w5•..............•....---•--•---...... Inspect .......... ...l-�_/l�1j..--r----- .....
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