HomeMy WebLinkAboutApp-Permit-ComplianceI /�
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THE COMMONWEALTH OF MASSACHUSETTS
BOARD OF HEALTH
.................OF.... .----------------------
Fx s ..............................
Appliration for Dhipoalork/)or
s Tonotrn.rfinrc .erntit
Application is hereby made for a Permit to Construct ( Repair ( ) an Individual Sewage Disposal
System at:
map )
_ - Locati Addr s or Lot No.
---- ._..¢��_ C, 27
-................
Address
.....
Installer Address
Type of Building Size Lot ... '.C�l.f.Ca ..Sq. feet
U.Dwelling — No. of Bedrooms_______._ Expansion Attic (Ndl Garbage Grinder QUC)
...... .......•-----••---.
P,, Other —Type of Building __V__%A-_---.-_----- No. of persons ............................ Showers ( ) — Cafeteria ( )
a Other fixtures ..................................
00M --�
W Design Flow.. -•...//.Q --_-------_-------------gallons per per day. Total daily flow ....... _..1__�15 ...................... gallons.
WSeptic Tank —Liquid capacity%WO.gallons Length6..`6 ". Width. -f.."/0."_ Diameter ................ Depth..) -___.6. °'
x Disposal Trench — No ..................... Width .................... Total Length .......... _......... Total leaching area .................... sq. ft.
Seepage Pit No..._/ ............. Diameter...13-__--__-_-_. Depth below inlet ...... ....... Total leaching area_as jO.0..sq. ft.
Z Other Distribution box (i� Dosing tank ( )
`•' Percolation Test Results Performed by..�_QA0_t..D.... A ...... 6/,6 Q0_A ..-..S== Date.iC---
Test Pit No. LAC�:..;Z _•minutes per inch Depth of Test Pit..../..2_....... Depth to ground water ........................
Test Pit No. 2................minutes per inch Depth of Test Pit .................... Depth to ground water ........................
--------------------------------------------....................................................... .........................................................
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Description of Soil-------- ` . 7.�... � ��sd 4_1V 1 ....-....S- 0113•. �C? =4=-----------------------------------------------••---
-----------316.. `�- •! --------- -------------------•----------------•------------------•--•--------
W
VNature of Repairs or Alterations — Answer when applicable._..............................................................................................
-----------------------------------------------------------•------------------------...-•-------...--------•--•------------------------------------------------------------------------.........--------
Agreement :
The undersigned agrees to install the aforedescribed Individual Sewage Disposal System in accordance with
the provisions of TITL - 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.
Signed...................................................................................... --- :.........
r Date
Application Approved BY ✓Lt,-?�..-sj
ate
Application Disapproved for the following reasons:....
................•---..........._......._._._......................------------------.......---...------------------------------------------------------- -.............. ---------
Date
PermitNo ......................................................... Issued-.......................................................
Date
THE COMMONWEALTH OF MASSACHUSETTS
BOARD
�irx#fu� O H>EALTH
......... ..l .. ............OF....
.................... ..............
i
of ft�unt�li�tnre
THIS ISS TO CERT„ h t the Individual Sewage Disposal System constructed (/orepaired ( )
bY.............. 4-•0�7------. �.��,�-------------------------------•------------------------------------------------------------------------------------......-----.......
T--11 --
has been installed in accordance with the provisions of TITL'E 5 of The State Sanitary Code s d cribed in the
application for Disposal Works Construction Permit No ... le -_-//6---------------- dated-._._ _ _. ZF ................
THE ISSUANCE OF THIS CERTIFICATE SHALL NOT BE CONSTRUE® AS A GU RANTEE THAT THE
SYSTEM WILL FUNCTION SATISFACTORY.
DATE .......................... - �.
= Inspector------- �_: � c
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