HomeMy WebLinkAboutApp-Permit-Compliance49,
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THE COMMONWEALTH OF MASSACHUSETTS
BOARD OF HEALTH
........ OF ..... .... % ( ... rH,
Appliratiou for Disposal Warks Toustrn.rtiun Vamit
Application is hereby made for a Permit to Construct ( X) or Repair ( ) an Individual Sewage Disposal
System at
Com�Ii............................................... P
j -- •__.... �'�--�� �
7•L cation -Address
4.7
Owner
Installer
- or Lot No.
Addres
Address
Type of BuildingSize Lot..._'t_-.,__1.__._______Sq. feet
Dwelling — No. of Bedrooms ............ ......................... Expansion Attic ( ) Garbage Grinder ( )
Other — Type of Building ............................ No. of persons ............................ Showers ( ) — Cafeteria ( )
Otherfixtures............................................-----------•-------------------------------------------------------------•-------•-
Design Flow.............1. ..................... gallons r pee�errpe day. Total daily flow ............... 2 .�----------- gallons.
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Septic Tank — Liquid capacity.). d Lgallons Length..&.. =+ {Width_'!_L'biameter________________ Depth -S=".9.
Disposal Trench — No ..................... Width .................... Total Length .................... Total leaching area ____________________sq. ft.
Seepage Pit No .......... C-......... Diameter ...... !_D_....... Depth below inlet --- L1 .... ....... Total leaching area.._--z6__7.sq. ft.
Other Distribution box Dosin`g tank
Percolation Test Result Performed by.7�_�a kjP'6.( _.__.._CA.�j� y______________ Date_ U1-:�._._.3 Q,1.__. _.�.
Test Pit No. 1 ____.__minutes per inch Depth of Test Pit ... .�__7.. __ Depth to ground water____`______________
Test Pit No. 2 ------------- ___minutes per inch Depth of Test Pit .................... Depth to ground water ........................
-------------- --------------------- ---------------------- __.... •---------- _----------------------- -------------- •------------------------------ ••----------
Description of Soil. -O.... .---•--- _i _.!a ..." Ali ' -------------------------------------------------------------•-----
--------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------
Nature 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 TITLE 5 of the State Sanitary Code — The undersigned further agrees not to place the system in
operation until a Certificate of Compliance has bee issued by the board of health.
Sign •--- --6 -•-
----------------------------------•-- /•--• • .
Application Approved By ........ • G ... ------------------------------------- ---- E _ -
Date
Application Disapproved for the following reasons:. ---------•- -----••---•----•••-•---••------•••---•-----•••--••-•-••----------•-----•.......................
..............................••••---•--••----••--------•••••----------•------•-----••---------------•-•---......._......_..--•-•--•--............................................. ---------------
.r . Date
Permit No ..... Issued ________--- r
Date
THE COMMONWEALTH OF MASSACHUSETTS
BOARD OF HEALTH
................./..G!G i2%..OF....::f�:.:`% :':.._......_.....................................
Tnrtifiiair of Tuntpliatta
THIS IS TO CERTIFY, That the Individual Sewage Disposal System constructed or Repaired ( )
Installer
QL_____---- __------------ ____________y__...___e.....--....._.:_a:...... !-----_..__________.______._______.____________..._.____________._._____ ______________._..___._.____________.___________-
has been installed in'accordance with the provisions of TITLE, 5 f The State Sanitary Code as described in the
application for Disposal Works Construction Permit No._t _�'______ ._,�!................ dated ------- _,XI'l-: ___.__
THE ISSUANCE OF THIS CERTIFICATE SHALL NOT BE CONSTRUE® AS A GUARANTEE THAT THE
SYSTEM WILL FUNCTION SATISFACTORY.
DATE ..........::.._- .....
. ... -- --f .................................... Inspector....!.:--- -=_ - ........ --- ------•-----