HomeMy WebLinkAboutApp-Permit-ComplianceNo.._3 ......... ...... FEB `
THE COMMONWEALTH OF MASSACHUSETTS
BOARD OF HEALTH t
6.lrV OF...YRR ovrt4
Appliration for DiSpos al Mirks Tonstrurtion Prrutit
Application is hereby made for a Permit to Construct or Repair ( ) an Individual Sewage Disposal
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M/1 C lip
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o tion - Add ss or Lot No.
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Owner Address
a -----------------------------------
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Installer Address �S 77
UType of Building Size Lot ............................ q. feet
,Dwelling —No. of Bedrooms ........ .................................... Expansion Attic ( ) Garbage Grinder ( )
Other — T e of Building No. of persons ............................ Showers — Cafeteria
a' Other fixtures ..................................
W Design Flow ............... :...............\5—Y.—...gallons per person pgr day. Total daily �flow ...................... 3 9 --_•.--•gallons.
WSeptic Tank — Liquid capacity%Q .gallons Length a.'.&._.. Width4.._lU _... Diameter ................ Depth.] ¢.._..
x Disposal Trench — No ..................... Width r...._...�........_. Total Length .................... Total leaching area .................... sq. ft.
Seepage Pit No ...... I ............. Diameter.L._f z..... Depth below inlet. -I............._. Total leaching area...! d :f -._sq. ft.
Z Other Distribution box (K) Dosin tank
`" Percolation Test Re Its Performed by._i!...................................... Date ----------
,aa Test Pit No. f,(/ 4Lminutes per inch Depth of Test Pit -13 2 `. �...... Depth to ground water[?...
Test Pit No. ,�•-----..._-•--minutes per inch Depth of Test Pit .................... Depth to ground water ........................
---N.eDescription of Soil ..... 12........� 4.=---- ve...---4---/6om gAlV uNoFC` ..
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Nature of Repairs or Alterations — Answer when applicable..................................................................
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Agreement : ie'
The undersigned agrees to install the aforedescribed Individual Sewage Disposal System in accordance with
the provisions of TI TIE 5 of the State Sanitary Code — e undersi ned rtlier agrees not to place the system in
operation until a Certificate of Compliance has been is e e b of ealth.
igned-------- •• .--•................................................................ �. �`-----------
D e
Application Approved By- =....................................................................• - Y .....................
i
Date
Application Disapproved for the following reasons---------------------------------------------------------------------------------------------------------------•.
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Date
L
Permit No. .... Issued -g 6--�---------------------------
--�------------------- Date
THE COMMONWEALTH OF MASSACHUSETTS
BOARD OF HEALTH
.......................................... OF .....................................................................................
At
wrrfi irttte of Tomplianrr
THIS IS TO CERTIFY at the I v>dual Sewage Disposal System constructed --(� ) or Repaired ( )
by------- _ a --- ��...... •-In 1� ----------------•-------------------------------_-------------------------._.-------•---------
at.-----_--...... _. �.... _' ...._ -'l'( -5�- ---------------------------------------------------------•-----------------•---------------
has been installed in accordance with the provisions of TI�` 5 of he State Sanitary/Code as scribed in the
application for Disposal Works Construction Permit No.__Ci��._... �______________ dated__
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THE ISSUANCE OF THIS CERTIFICATE SMALL NOT BE CONSTRUED ASA NTEE THE
SYSTEM WILL_FU CTIQN SATISFACTORY.
DATE._._.. ,.�s -Z2------------------------------------------Inspect r