HomeMy WebLinkAboutApp-Permit-ComplianceKEM 0 V,46
No. Z.6 J ....... Fm3... 0..
THE COMMONWEALTH OF MASSACHUSETTS
BOARD OF HEALTH
�U
............... OF............yQq..N .............................................
Appliration for Uiiposal Works Ton,strurtion 11trutit
Application is hereby made for a Permit to Construct (✓) or Repair ( ) an Individual Sewage Disposal
System at: r a ,,
......... --------------------- - --- -- . ......................
Location - Ad res; ` or Lot No.
.._... 1 � N.M i...----•-----•------------------------------------------------------------------------------------------------------------- -............... -......
Owner Address
Installer Address
Type of Building Size Lot .... ,_v73......... Sq. feet
Dwelling —No. of Bedrooms ..._....3 ..............................Expansion Attic ( ) Garbage Grinder ( )
Other — Type of Building ............................ No. of persons ...... _..................... Showers ( ) — Cafeteria ( )
Other fixtures .....
-------------------
-----------
Design Flow ................. 1�Q.------.-.-.---.---..gallons per-perserr�_`' A.
per day. Total dailyflow -_-•---_33o......--................gallons.
Septic Tank — Liquid capacity i� .gallons Lengthd. ._._. Width::j �.__ Diameter________________ Depth K 4".....
Disposal Trench — No ..................... Width .................... Total Length .................... Total leaching area .................... sq. ft.
Seepage Pit No......... ----------- Diameter ..... 10......... Depth below inlet ....... C----------- Total leaching area.. -T61 ...... sq. ft.
Other Distribution box Dosing tank ( )
Percolation Test Results Performed by........................2 ._-O: (�IE{�1ZN (NC:-• Date...@. Zi:gs_'Ao _3_ _8S -
Test Pit No. I ... G? .._..minutes per inch Depth of Test Pit. ---- IW8------- Depth to ground water ........................
Test Pit No. 2.-- 5 Z .... minutes per inch Depth of Test Pit... PO_ _ __ Depth to ground water ........................ FNc
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Description of Soil.-•----�-' ��_._---------------------------------------------------------------- -_ 14." 57... M
b l03 f-i�'D 3�_ ht�_ S�Q--------------------------------------5 r�tn -
3640
-----------------•------------. IQs ' _ �Zo•- .. U''.------------•------•------------•--------------------- ... .....
Nature of Repairs or Alterations — Answer when applicable ................... J /1i - Fi c SnIJ Q
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--•-•---•------------•-----•-------------•-•-••-----•--•--•._._._...----•-......-------------------•--------------------..Z-- . Z ---n u-......•-•----•----------............---......... .
Agreement:
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 system in
operation until a Certificate of Compliance has been sued by the board of health. +
l
Application Approved By
Application Disapproved for the following recons:...
------------------------------------•----------..........--------•-----........---------..........--•-•-------......--------------
�y 0 r Date
Permit No.1.<..:.�.7
- Issued • n %....... - -
THE COMMONWEALTH OF MASSACHUSETTS
BOARD OF HEALTH
±.......................... OF... °.:.::: r:........:..:......................................................
Trr#ifiratr of Tontplittnrr
pTH,IStI�S9-0 BERT FY, That,.,the Individual Sewage Disposal System constructed ) or Repaired ( )
byC`a%51 ---- •--•----•-•--•-••-•--•-•---------------•-•---••-••-•----..........--••--•-------
I UP
nsat tal
---y--- ._ ._..._. _......_ ..._ 't•'-°- -------------------------- ---- •------•--' - --- --'
has been installed in accordance with the provisions of.. TWIT �-5 of The State SanitaCodda? s m the
application for Disposal Works Construction Permit No................... dated `_f.=°'_ _ _ �. .
t
THE ISSUANCE OF THIS CERTIFICATE SHALL NOT BE CONSTRUE® U NTEE THAT THE
SYSTEM WILL FUNCTION SATISFACTORY.
DATE.. i f f al ..................... . ....................... Inspector.�°��•----------- - -- ..... ........... ------------------.
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