HomeMy WebLinkAboutApp-Permit-Compliance__.. Fmm .......................
THE COMMONWEALTH OF MASSACHUSETTS
BOARD OF HEALTH
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Appliratinn for Disposal Works Tonstrnrtion 11nmit
Application is hereby made for a Permit to Construct (VO) or Repair ( ) an Individual Sewage Disposal
System at:
............ �C/?o9n1EtZL. AADT
Location • Address%, or Lot No.
_
------• •-•----••---•---••---
Owner Address
Installer Address
Type of Building Size Lot._3- .20oa..._.___Sq. feet
Dwelling —No. of Bedrooms ______________3.._._._........•.___.__.Expansion Attic ( ) Garbage Grinder ( )
Other — Type of Building •...... .................... No. of persons ............................ Showers ( ) — Cafeteria ( )
Otherfixtures--------------------------------------------------------•-•---•--•-----•------------•-- ..............................................................
Design Flow .._.._..�I............................. gallons per person per day. Total daily flow _____39v___._._________._..__._____gallons.
Septic Tank — Liquid capacity API2__gallons Length ----- Ze?.,9.7,- Width ... s _ Diameter ................ Depth__'0�- __
Disposal Trench — No ..................... Width .................... Total Length .................... Total leaching area ............ _------- sq. ft.
Seepage Pit No ------- 1----------- Diameter ....._. o�e_Gt__ Depth below inlet --- fT ..... Total leaching area.?4........ ft.
Other Distribution box (✓) Dosing tank ( )
Percolation Test Results Performed by-.TFt :;i i--___ .. c y, •Pnjg;............ Date. __&p 1978
Test Pit No. 1...?hlo...... minutes per inch Depth of Test Pit.._;44 _...._ Depth to ground water_ Wiq#'! t
Test Pit No. 2................minutes per inch Depth of Test Pit .................... Depth to ground water ........................
of Soil.._ 01, in'�--_Wnur� lb/�-rl /0" -30" Sv�g_ Sv> e --
Description 3d`� /4¢_....... . ./v,!. ..............
.......................... -------------------------------------------------------------------------------------------------------•----•-•--------•-------•------ •-•------••••.......................
Nature of Repairs or Alterations — Answer when applicable ._______________________________________________________________________________________________
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Agreement:
The undersigned agrees to install the aforedescribed Individual Sewage Disposal System in accordance with
the provisions of ;
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.
n .0 . f
Application Approved
Application DisapproveWr the following—reasons: ............................
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G%
Permit No ...... 9 f .................................
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Da
Date
Issued_ ........................
Date
THE COMMONWEALTH OF MASSACHUSETTS
BOARD OF HEALTH
------------
Date
........................�. e?v........ O F.... >` r ,>,..............................
Trr#ifirat of Bunt rli nrr
THIS IS TO C�-TIFY, That the Individual Sewage Disposal System constructed ( ) or Repaired ( )
b- -------------- --------------- -------------------- - ----
y -
- Inst ,
. / ally' i
has eri installed in accordance v6ith th�isions of TITA,::!jd
j of The State SanitarydCe as de ribed in*"application for Disposal Works Construction Permit No.__._.___________________ dated__ _ :s....._..._.•......
THE ISSUANCE OF THIS CERTIFICATE SHALL NOT BE CONSTRUE® AS A RA TEE THAT THE
SYSTEM WILL F NCTION SATISFACTORY.
Inspector------•--..DATI..............------------------- ...