HomeMy WebLinkAboutApp-Permit-ComplianceNo�f747
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THE COMMONWEALTH OF MASSACHUSETTS
BOARD OF HEALTH
Ci. � �. �✓`r ...... OF ...........�t.....................................
Appliration for Disposal Works Tonuirurtion f rrmit
Application is hereby made fo P rmit to Construe
System at: Ly ov lG
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Installer
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Construct
( ) or Repair ( ) an Individual Sewage Disposal
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.................
................. . ».------•-- -!
l. ...... .............................................Lot No.
Address
................... -------......-----•----•---------------------------
Address
Type of Building T Size Lot ............................ Sq. feet
Dwelling — No. of Bedrooms.... ��...................................Expansion Attic ( ) Garbage Grinder ( )
Other — Type of Building ............................ No. of persons............................ Showers ( ) — Cafeteria ( )
Otherfixtures ................•------------........--......---•--....--•--............------........--------------•-----•:-_-_-----•--------••-----•......._..------
Design Flow....... ......................gallons per person per day. Total daily flow ........ ._3 ... %.................. gallons.
Septic Tank — Liquid capacityl� gallons Length..... ce.__. Width.. --------- Diameter ................ Depth ................
Disposal Trench — No. ___/ .............. Width ....... 2......__. Total Length._____& .. Total leaching area -------------------- sq. ft.
Seepage Pit No ..................... Diameter .................... Depth below inlet.................... Total leaching area ................. sq. ft.
Other Distribution box ( ) Dosing tank ( )
Percolation Test Results Performed by.......................................................................... Date ........................................
Test Pit No. 1................minutes per inch Depth of Test Pit .................... Depth to ground water ........................
Test Pit No. 2................minutes per inch Depth of Test Pit--.................. Depth to ground water........................
Description of Soil
----------------------------------------------------------------------------------------------------------------------•--•-------•---- -•--------•--------•----...........--------------------
Nature of Repairs or Alterations - Answer when applicable.... ...i 7f+.. �.....- _1'.fl.:-. OE -2. ....� �? � � 'tri'= �
Agreement:
The undersigned agrees to install the aforedescribed Individual Sewage Disposal System in accordance with
the provisions of TITIS 5 of the State Sanitary Code — The undersigned further agrees not to place the system in
operation until a Certificate of Compliance-lailLe—en issued by the h.
Signe .. `� --
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ApplicationApproved By ......... .--.................................................................... .�� -. Date '-------.._.
Application Disapproved for the f olio 'ng reasons----------------------------------------------------------------•--•----------------•-------•--•---........»--
Permit No.._......t7� � ..............»....
.-------------•-----------------••----•---....----•-------.....----------
Date-
Issued------------- - /1� �.
..........
Date
THE COMMONWEALTH OF MASSACHUSETTS
BOARD OF HEALTH
........ OF.. ..................
(arx#ifuttte of Toutplittnrr
Tk[I,S' IS TO CE.I�TIFY, That the Individual Sewage Disposal System constructed ( ) or Repaired ( Cj_
�
Installer
at(D (J -D------`--- -------. . .......... C'.. �' T"----------------'.................................-----•------......----------....-----------
has been installed in accordance with the provisions of T T.,�,E 5 of The State Sanitary C ;jS fser the
application for Disposal Works Construction Permit No.. �L��................. date .-. _:_!. �s.'?------.-
�+
THE ISSUANCE OF THIS CERTIFICATE SHALL NOT BE CONSTRUED AS R N E THAT THE
SYSTEhA W L__
U CTIO//.N -SATIS ACTORY.
DAT- i ---------------------- Inspector ``-- - `���-� ,-- - ` -`�--- -- .._../