HomeMy WebLinkAboutApp-Permit-ComplianceNo.. 7.9-389 ------ Fim$.... $15,. 0.Q.....
THE COMMONWEALTH OF MASSACHUSETTS
BOARD OF HEALTH
OF.........r�GZ!'"mT.................................
............ ...................
Appliration for Uh4poiial Works Tonstrnrtion .rrmi#
Application is hereby made for a Permit to Construct (X') or Repair ( ) an Individual Sewage Disposal
Systern t*P16o� _ ".c� i
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L tion -Address
s-.._err-�v _ ..Lhc.-----•--- �/.T/c.!�::-D:.laie�e!
............ _.._...�.... so-----------------
/ � Owner Address •-
.......................... ----------
Installer Address
Type of Building Size Lot .... �t,�.7� ... Sq. feet
Dwelling — No. of Bedrooms .............. Z.._.__._._._.__.._....___Expansion Attic ( ) Garbage Grinder ( )
Other — Type of Building ............................ No. of persons__-___.___.____._---___-___- Showers ( ) — Cafeteria ( )
Otherfixtures-•-----••-------•---------------------•--------------•-----------------------•------------------••-------•--------...-------------------•--•---------
Design Flow .......... .--------------------------------- gallons per person per day. Total daily flow ............... ... 4.
Septic Tank — Liquid capacity/ !d..gallons Length ................ Width ................ Diameter ---------------- Depth ................
Disposal Trench — No. ____1._______-___ Width._._. Z'.__.__._ Total Length----- Z`_._.._. Total leaching area_g ------- sq. ft.
Seepage Pit No --------------------- Diameter .................... Depth below inlet .................... Total leaching area .................. sq. ft.
Other Distribution box (X ) Dosing tank ( ) /
Percolation Test Results Performed by. �- �a%� �!!' l"! _ ' ..... Date --- V ..l...__31s__ 9.79.
Test Pit No.'1... G Z___minutes per inch Depth of Test Pit._/Z.1......... Depth to ground water.- /i%!�_._.
Test Pit No. 2................minutes per inch Depth of Test Pit .................... Depth to ground water ........................
W--- -- ----------- -------------
Description of Soil -O=.."' `----/021✓irz.arl
2 - �f c cl._.dv'------------
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Nature of Repairs or Alterations — Answer when applicable_.
Agreement:
The undersigned agrees to install the aforedescribed Individual Sewage Disposal System in accordance with
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the provisions of � �.: � 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.
Si ne d
Application Approved By----------- .... 2- ....... -------------------------
Application Disapproved for the following reasons:.
PermitNo---------------------------------------------------------
Date
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Date
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Date
Issued_.......................................................
Date
THE COMMONWEALTH OF MASSACHUSETTS
BOARD OF HEALTH
.......................................... OF .....................................................................................
Trrtifiratr of Tontpliatta
THIS IS TO CERTIFY, That the Individual Sewage Disposal System constructed (X) or Repaired ( )
by-•-----•-------•-••OR........................................................................................................................................................................
Installer
at ............................. WT_.2f12--- ... ►OPPER-.3ROJOK - 9 +' -----------------------------------------------------------......---------------
has been installed in accordance with the provisions of TITiE j of The State Sanitary Code as described in the
application for Disposal Works Construction Permit No ----------------------------------------- dated __.._-__._.-_____._._______----_._.--_-___-----.
THE ISSUANCE OF THIS CERTIFICATE SHALL NOT BE CONSTRUE® AS A GUARANTEE THAT THE
SYSTEM WILL FUNCTION SATISFACTORY.
DATE....................................•--------------------------------------•---- Inspector