HomeMy WebLinkAboutApp-Permit-ComplianceTHE COMMONWEALTH OF MASSACHUSETTS Fes$..
_ BOARD rOF HEALTH
6W /S/-------------OF...........T .jeM . _ -7z...._.._..............
Apptiratiou fox Disposal orki Tomuur#torn Vrrmit
Application is hereby made for a Permit to Construct (X) or Repair ( ) an Individual Sewage Disposal
System at: _ y�
- --...... ` . ��` l...- -V �-- ......--•-----•--••-------------
....... r ...... q-.................... ! -
Lo a ion - Address or Lot No
....... ............j��.AcAs .. ...., ..V�- 4 .......................
- caner '�- i� Yds_1-J-1..
.............�f6 .....:�----------------------------------- --------- -----A-------
Installer Address
Type of Building Size Lot .... J6 _04 .-Sq. feet
Dwelling — No. of Bedrooms--------------- 3. ------__-----_-___---_Expansion Attic ( ) Garbage Grinder ( )
Other — Type of Building ............................ No. of persons ............................ Showers ( ) — Cafeteria ( )
Otherfixtures-------------------------------------------------------------••-----•--••--------------•-•-----------•----------- ....................................
Design Flow..............4T_.................. gallons per personer day. Total daily flow -------------- -3.0 ............... gallons.
Septic Tank —Liquid capacityJ12PVgallons Length ---- Width.....`......... Diameter ................ Depth...4_....___
Disposal Trench — No- -------------------- Width .................... Total Length .................... Total leaching area .................... sq. ft.
Seepage Pit No -------- t---------- Diameter.._.. e_! ----- Depth below inlet ...... 4......... Total leaching area..Z012.... sq. ft.
Other Distribution box X) Dosing tank ( ) — Z!7 — %8
Percolation Test Results Performed by....__�. __ T ---------------- Date -.,g.—
Test Pit No. i..,5:�Z—_minutes per inch Depth of Test Pit ...... /Z:...... Depth to ground water/Vd7:..j6//42CUAJ7-
Test Pit No. 2400 per inch Depth of Test Pit ...... _--- Depth to ground water..
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� �f:�� .3FDescription of Soil-- ........ --.... :-------------- T---�.
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Nature of Repairs o: Alterations — Answer when applicable................................................................................................
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Agreement : '`I
The undersigned agrees to install the aforedescribed Individual Sewage Disposal System in accordance with
therovisions of 'IT..
p 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 board of health.
Date
igned------------------- ---------------------------------------------------------------- --------------------------------
ApplicationApproved By...........................G ._._.....L .=--------------------•---------------------------- -------- ��.._
Application Disapproved for the following reasons: ---•----•--------•---------------------------------•-------------•-•------------------------••--------------•---
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Date
PermitNo ......................................................... Issued .......................................................
Date
THE COMMONWEALTH OF MASSACHUSETTS
BOARD OF HEALTH
............................... I.......... OF .....................................................................................
Qurrtifiratr of Tompliaurr
THIS IS TO CERTIFY, That the Individual Sewage Disposal System constructed( ) or Repaired ( )
------------------------------------------------------ --------------------------------------
f Installer
at -....-------vi--------------------------
--------- --- --- b---------------------------------
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has Peen install in accordance with the provisions of TIT -it ; - of` The State Sanitary Code as described in the
application for Disposal Works Construction Permit No.;. -___.._ dated__..,_,. ,� __.......................
{r -a_
THE ISSUANCE OF THIS CERTIFICATE SH OT EIt' ,teNSTRIIE® AS A,44' A
,N EVHAT THE
SYSTEM WILL FU CTION SATISFACTORY.
2—
)1611_�
DATE ........... .......................
....................................................
� ... Inspector