HomeMy WebLinkAboutApp-Permit-Compliance4 THE COMMONWEALTH OF MASSACHUSETTS
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BOARD OF HEALTH
..... .....OF......././L w
Appliration for Disposal Works Tonstrur#ion Fermi#
Application is hereby made for a Permit to Construct
y \ System at • -
�jC . •---•---•--.. .: .AA.M nv .............._...•.......
� ^ 'o • Ad r ss
........ 1. ....__... ..._..
er
Installer
Type of Building
Dwelling —No. o
Other —Type of
or Repair 4/) an Individual Sewage Disposal
'Size Lot ............................ bq. feet
f Bedrooms...................................... Expansion Attic ( ) Garbage Grinder ( )
Building ............................ No. of persons............................ Showers ( ) — Cafeteria ( )
Otherfixtures-----•------------------------•-----...................---••---•-----------------•--------.....------.
Design Flow............................................gallons per person per day. Total daily flow ............................................ gallons.
Septic Tank — Liquid capacity ............ gallons Length ................ Width ................ Diameter ................ Depth ................
Disposal Trench — No ..................... Width .................... 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. I................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........................
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Descriptionof Soil ...............................................................................
•-•-••••-•----------------•-----•------•-...-•---•-----••-------------•-------------••----------------------------------------•----------------...............---------•-----------••---•---------•-----
----...-••--•----•--•-•----•••----•-•-•---•---••-------•------••--------------•-•-•-•------•--•---------•-•-•---------- .....••..-----•----------- ........
Nature ofRepairs or Alterations Answer when applicab e___9 !✓ __.._._1.1132__
Agreement:
The undersigned agrees to install the aforedescribed Individual Sewage Disposal System in accordance with
the provisions of TITL Z 5 of the' State Sanitary Code — The !3AYersigned further agrees not to place the system in
operation until a Certificate of Compliance has been ispdby%o�rd of ie 1 h.,
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Application
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Application Approved By---•- - '-- . -- .----•-..... ........ ...... �`�
e
Application Disapproved for the following re ons:-------•-----------------------------------------------------------------------------------•--••----....---•....
G- 1Af
Permit No..�v---`�'SJR----•-----•..................... Issued. ------ *-------- -0-----•--nau......
THE COMMONWEALTH OF MASSACHUSETTS
BOARD OF HEALTH
.......... ...........................
Coir tiftrtt a of Tout Iittnrr
THIS IS_'O CERTIFY_Ibat the
S7stem constructed
by ..........
. G ::..........) =--•-- L' vs- = ' '..........................................
/� In rer
at ...... Z ..... 1 / �� r ' / G '�. v!__..--.1.
has been installed in/accordance with the provisions of T jTRLE of/ The State Sanita Co
application for Disposal Works Construction Permit No.=:h................ dated. . _._. .
THE ISSUANCE OF THIS CERTIFICATE SHALL NOT BE CONSTRUE® AS G R
SYSTEM WILL F N TION SATISFACTORY.
DATE --------------7 --- 7• � f�--•---.------------------•-----------•---• Inspector.._
or Repaired (1,1�
s- described in the
THAT THE
LI
so