HomeMy WebLinkAboutApp-Permit-ComplianceTHE COMMONWEALTH OF MASSACHUSETTS
BOARD OF HEALTH
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_OF .............
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Appfiration for Uhipaotti 19urkii Tonrittunion 11rrmit
Application is hereby made for a Permit to Construct (1-) or Repair ( ) an Individual Sewage Disposal
System at: /
ILS_ r'PDV(_:� Yor(r,ju�h) l_Q7-A--7n fiipp -?cl
Owner
Installer
Address
Address
Type of Building 7:7' Size Lot .-..-_Grt_�S7__J-Sq. feet
Dwelling —No. of Bedrooms ------------------_-----------------.....Expansion Attic ( ) Garbage Grinder
Other — Type of Building ............................ No. of persons .............. .............. Showers ( ) — Cafeteria ( )
Other fixtures ------------------ --------------- - .....-...-..
FE m
Design Flow -----------------J L ------------.-..gallons per Feson per day. Total daily flow ........... - i1............. ---.... gallons.
Septic Ta 1�5Liquid capacity. ... ...----gallons Length---------------- Width ........ Diameter ............ .--- Depth-......-........
Disposal a — No. ........ j.-.. Width..._ e.: ....... Total Length .... 2..5-....... Total leaching area ...... I..L6..sq. ft.
Seepage Pit No ..................... Diameter.-.................. Depth below inlet ... ....--........... Total leaching area-.- ............... sq. ft.
Other Distribution box (,p) Dosing tank ( )
Percolation Test Results Performed by... --.-.-- ......................4-....-.-._....-. Date ..... ...............
Test Pit No. 1. -..C -`:...minutes per inch Depth of Test Pit ... --1_�'Z- L.--. Depth to ground water ...... .---..-......
.
Test Pit No. 2_� t :---..minutes per inch Depth of Test Pit.....'t ....... Depth to ground water-----!: B.`.......
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Nature of Repairs or Alterations — Answer when applicable.................... - ?. ! Z- .....
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Agreement:
The undersigned agrees to install the aforedescribed Tndividual Sewage Disposal System in accordance with
the provisions of TITLE: 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 boat- f health.
n . —,t. \\11
Application Approved
-*Dle
Application Disapproved for the following
THE COMMONWEALTH OF MASSACHUSETTS
BOARD OF HEALTH
.......:.......... Y.2...............__OF .............:...............................-•--...................................
(9rdifiratr of Tompliana
TFIjS IS T O CERTIFY, Tl #a he Individual Sewage Disposal System constructed ( or Repaired ( )
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by- r / ' / ----- •----•--•- 7J
1 l / I dt .. ..;��-' nista, /.
has been installed in accordance with the provisions of TITLE 5 of The State Sanitary Code as described in the
application for Disposal Works Construction Permit No.--- dated .... :::...._r_' ............................
....
THE ISSUANCE OF THIS CERTIFICATE SHALL NOT BE CONSTRUED AS A GUARANTEE THAT THE
SYSTEM WILL FUNCTION SATISFACTORY.