HomeMy WebLinkAboutApp-Permit-ComplianceNo..?2.—/05-
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THE COMMONWEALTH OF MASSACHUSETTS
BOARD OF HEALTH
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Appliratiun for %qisuoal Warlto Tonutrurtiun Frrutit
Application is hereby made for a Permit to Construct ( t l or Repair ( ) an Individual Sewage Disposal
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Locatioji I Address
D,.
Installer
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i or Lot No. 91X
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Address IAF'
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Type of Building -3 Size Lot-- -...r..............,
) ...Sq feet
Dwelling— No. of Bedrooms............../............................Expansion Attic ( Garbage Grinder
Other—Type of Building ._...............__...... No. of persons.. .................... ...... Showers ( ) — Cafeteria ( )
Other fixtures .................................
Design Flow.......L/'9 .........................gallons pen p lan er �Y. Total dally Aow..-..--.-......3_ U �lon�.
........................................................•-........ -----
.... Diameter............_ Depth ..............
Septic Tanlc—Liquid capacity���.gailons Length �-.. Width. GU.... �.� /
Disposal Trench — No ..................... Width.................. Total Length ............. Total leaching area ........... ......... sq. ft.
Seepage Pit No ..... _1.......... Diameter.........�0.... Depth below inlet. ...... ....... Total leaching area..:2�..7.sq. ft.
Other Distribution box (� Dosing tan ) ) G
Percolation Test Resins— Performed b y` .......... .................. ............... Date.......
Test Pit No. 1................minutes per inch Depth of Test Pit.../.r.75]..._.... Depth to round water....!..........-�y.
Test Pit No. 2.G --....minutes per inch Depth of Test Pit../.Z®........ Depth to ground water ... 71......
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Nature of Repairs or Alterations — Answer when
Agreement:
The undersigned agrees to install the aforedescribed Individual Sewage Disposal System in accordance with
the provisions of TITL : 5 of the State Sanitary Code — The undersigned further agrees not to place the system in
operation until a Certificate of Compliance has been is ued by the board o health. `
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Da1wjApplication Approved y--- -------- -- ------'''`�---------- + - ....
Date
Application Disapproved for the followinrg reasons:
Permit No ........ V2: /05 .................
THE COMMONWEALTH OF MASSACH UST75
} BOARD OF, HEALTH 4
........1........1..._OF ................ ..t:.::.:...Y..`.. i l) ........
Trrtifiratle of Toutpliatta
THIS IS TO CERTIFY, That the Individual Sewage 1
i . i Installer
Date
System constructed
Date
) or Repaired ( )
has been installed in accordance with the provisions of TIT,,FTEt 5 of The.State Sanitary Code as described in the
application for Disposal Works Construction Permit No....., . _... y'5 ...::............. dated.... .-:.....
' .._-..-.,.
THE IS UANICE OF THIS CERTIFICATE SHALL NOT BE CONSTRUED ASA GRANTEE THAT THE
SYSTEt'A 4Y L FUNCTIO ^SATISFACTORY. I J� , +
DATE.... G� . Z- - -C.................................... Inspector..... �/�