HomeMy WebLinkAboutApp-Permit-ComplianceNo.3/..�.:....
THE COMMONWEALTH OF MASSACHUSETTS
Fps.........................
BOARD OF HEALTH
/�/ ..... .............OF..........._...- E. %J fv�
New
Appliraft on fear DI-Spoi4lVorks Tnntrnrtion Famit
2 6 Muscae
LtJ. Applidation is hereby made for a Permit to Construct ( ) or Repair ( ) an Individual Sewage Disposal
System at: 5g'
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..........
-Address r or t N
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t�ddres
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,-� ..... �---........-•................ ...... �....-:..-------•-•---•-------------•. �'� /�� .----- - / �.. �. ---✓•
n 1 er
ype of Buil in � S--------
Tze Lot. Z t'iA�!? ........ Sq. feet
U Dwelling —No. of Bedrooms ........... ............................. Expansion Attic ( ) Garbage Grinder ( )
`4
A4 Other —Type of Building No. of persons ....... ................ Showers ( )Cafeteria
C4 Other fixtures -----•--•-_------_--- ---------•---•------
Design Flow.....................r--------------- gallons per person_er �i�y. Total cl�aily flow._......_.?�3.v._._......_..:__._._dons.
WSeptic Tank — Liquid capac' y1000__gallons Length.. _.' t..... Width.Y''G��.. Diameter --- '... Depth.-...-r.V _.
x Disposal Trench — No... O/A....... Width .._.. ��:r!!::
...... Total Length :::: Total leaching area......... sq. ft.
Seepage Pit No._.. -_I........... Diameter ...... 10........ Depth below inlet ...... fa_......... Total leaching area ... ?4& ..... sq. ft.
Z Other Distribution box (}01"') Dosing tank ( )
~' Percolation Test Results Performed by.. i.._. r :.. Date__ � /'_.....__...__....
aTest Pit No. 1... A Z -_..minutes per inch Depth of Test Pit .... f . ....... Depth to ground water.J,!�!' _E:........
Test Pit No. 2.....-�minutes per inch Depth of Test Pit ........... _.... Depth to ground water._!! . ..............
....................................................... ---------------•----•------------------------------------
9--------------------------•----------------------•---------------•Description of Soil..... - SQ
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P.? -``/{--------------------------•-------------•---..............................
ItAl
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Nature of Repairs or Alterations — Answer when applicable..............___..__.__......_..........................•..__...............................__.
Agreement :r'
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 sys em in
operation until a Certificate of Compliance has bejissby° �gard j�. �ed.-----.................................................•-•--- ----- ------••-•-----------
A lication A rcSved B - -- -- - ----------•----....--•------•-•-----•--•---. ---- --- .... -DPP PP y ------.Da
Application Disapproved for the following ason--------------•---•-----------------------------•---------------•----•--------•----••-......------
--------------------------------•-------�----------------•-------•---------•--------------------------•.....----------•-----•---...-•-O G------.
Permit No......T-----------� I- ........... _.._ Issued _.......... r-1.Vjr ------
Dfite
THE COMMONWEALTH OF MASSACHUSETTS
_ BOARD OF HEALTH
......c.^%............................ OF....'G %yl .................................................
(Irrfiftrati of TomPlUturr
THIS. CERTIFY, That th�ndivi�ual Sewage Dispo 5 tem construct ) or Repairedby
( )
xnatatlw
at................................................... ........................ ....... .. .-•--- ............................ ........................
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 ......................................... dated ................................................
THE ISSUANCE OF THIS CERTIFICATE SHALL NOT BE COMRUED #S-*,GUARANTEE,7P THE
SYSTEMA WILL FUNCTION SATISFACTORY..
DATE..... ....................... Inspec