HomeMy WebLinkAboutApp-Permit-ComplianceNo...�/..�.... Fns 036. ...............
P'nfrivez THE COMMONWEALTH OF MASSACHUSETTS
BOARD OF HEALTH
lf�/�lI/ S�1rivS %J%�
. . ..................OF............. `...... ./sd_�...
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Appliration for Bi,-qVooal Work,q C9nmitrnrtion 11rrmit
Application is hereby made for a Permit to Construct ( t or Repair ( ) an Individual Sewage Disposal
System at:
................•••..........---•------------------- k Y1>3.P... -4
Address or Lot No.
Ita'... `°`.`-.. /� ✓� of �v � ...... d✓cam ..........................
Owner Address
a- ------ - - --
Installer AddressU
Type of Building Size Lot..."}........./Sq. feet
Dwelling—No, of Bedrooms............................................Expansion Attic ( ) Garbage Grinder (-✓i-Y�
'4 Other—Type of Building No. of persons ............................ Showers — Cafeteria
P4 Other fixtures ...................................
WDesign Flow... .... ��gallons per -person- e Total (d�a)ly Aqw............... `. ��_ .... 1p s.Cl
WSeptic Tank — Liquid capacity(...........gallons Length. ....... Width -.`...(0... Diameter ---- ..------ ._. Depth......._..
Disposal Trench — No ..................... Width.................... Total Length .................... Total leaching area .................... sq. ft.
3 Seepage Pit No ........... I........ Diameter ........ ..h--- Depth below inlet,.. ....... ?. AT - ..... Total leaching area sq. ft.
Z Other Distribution box ( Dosing tank
Percolation Test Results^ Performed by.... ......... �.�i ..._.__ Date....
i'
�j Test Pit No. 1 ............minutes per inch Depth of Test Pit..�... C. ..... ... Depth to ground water .....
._.�.t /...
k Test Pit No. 2�.3.._minutesper inch Depth of Test Pit ... .. y... Depth to ground water .... 1E.t�..
lt� /GO Description of Soil v....._.. . .......... --(T.....
.?.0 .... ....
....'P..................................................
...--..................................-..............---- _..--...........................----- .................. ---------.......................
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 TITIZ 5 of the State Sanitary Code — The undersigned further agrees not to place the system in
operation until a Certificate of Compliancehas heen issued by the boa d f I� 1 he 7-v
...O..�......
Application Approved By�-�!kc!? C Q ......:....... ............................... .x.t`...PD'--------------
( Date
Application Disapproved for the following
p� / �- �,�` Date
Permit No. CX2- 65 ................................... Issueck ........ ... Yiz��gl / IIJ�P............
Dace
THE COMMONWEALTH OF MASSACHUSETTS
BOARD OF HEALTH
...k..lJZAJ......................... OF ....... tkN. �r(>t.{.T.�1...................................................
Tertifiratr of Toutplittnrr
THIS IS TO CERTIFY, That the Individual Sewage Disposal System constructed ( �0 or Repaired ( )
by... I ------------------------------------..................... .........................................................................................
has been installed in accordance with the provisions of TITLE 5 of The State Sanitary Code described in the
application for Disposal Works Construction Fermat No..itis:.4a.5ra................... dated ... /'i�t�i�§..?2�......................
....
THE ISSUANCE OF THIS CERTIFICATE SHALL NOT BE CONSTRUED NTEE THAT THE
SYSTE WILL FUgNQC�-TIION SATISFACTORY. - �.
DATE. �.J..�.l..tl_----------------............................... Inspector.'�.i........�.!� Cr--. (.