HomeMy WebLinkAboutApp-Permit-ComplianceNo.5.`.._-�J..39 Fas F..dJ...............
THE COMMONWEALTH OF MASSACHUSETTS
BOARD OF/1 HEALTr1H
.......Ta.Wkl............. OF...............�.&k.1.mQ..l..):1.-t-..L.---..........................
Appfiratiun for Dispootti Mirfw Tonotrurtiun Permit
Application is hereby made for a Permit to Construct X) or Repair ( ) an Individual Sewage Disposal
System at:
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Locatiot -Address
owner
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� Instnll<r
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W
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Type of Building
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Address
C"cyr,cic u1, ...........................................
Address
Size Lot.`4.z�.E.tUQT.:C.Sq. feet
Dwelling—No. of Bedrooms... ..........-..T............................Expansion Attic (AJC) Garbage Grinder (W)
Other — Type of Building ............................ No. of persons............................ Showers ( ) — Cafeteria ( )
Otherfixtures..........................................--------------..........................-- ..._.........-------................... ......------
Design Flow ................. 5_5.....................gallons per person per day. Total daily flow.. .1{--)-I-t -- ... .'7.Q....gallons.
Septic Tank —Liquid capacity-).l'�QQgallons LengthZ..!.11a."... WtdthA...Diameter .... .._.__..--- Depth.5....6.11
Disposal Trench — No ..................... Width .................... Total Length.... ................ Total leaching area ............_......sq. ft.
Seepage Pit No .......... 1......__. Diameter .......LQ. �.. Depth below Total leaching area..Z 1.7...sq. ft.
Other Distribution box ( )() Dosing tank ( )
Percolation Test Results Performed by ................................................... ... Date ........................................
Test Pit No. 4•:.... ..minutes per inch Depth of Test Pit.._1. ......... Depth to ground water.._P J.A........
Test Pit No. 2_ ............. minutes per inch Depth of Test Pit.................... Depth to ground water..._ - it
Description of
.............................................. rl.N.1:......
a,uJv! !-
Nature of Repairs or Alterations — Answer when applicable.... �.......
Agreement: ,�_"tea
The undersigned agrees to install the aforedescribed Individual Sewage Disposal System in accordance witi
the provisions of TITLE S 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 aboard otjbealjth!,jt
Application Approved By PEYLfiC'....✓J
Application Disapproved for the following reasons:
Permit No..41.!.:3.3.14..............................._ Issu ...... ......e..
Date
THE COMMONWEALTH OF MASSACHUSETTS
BOARlyD/ SOF" HEALTH
.........................OF....i.IIPAI:')///.!1.....................................................
Tntifirab of Tautplittnre
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That the Individual Sewage Disposal System constructed (() or Repaired ( )
has been installed in accordance with the provisions of £S 7 The State Sanitaryh C es dfcre the
application for Disposal Works Construction Permit No. ............................. dated...!.:';_!...'.
......... .
THE ISSUANCE OF THIS CERTIFICATE SHALL NOT BE CONSTRUED A Ca,1�i1jRANTEE THAT THE
SYSTE FUNCTION SATISFACTORY. /��//y
DATE.. ..._....... X - Inspect �t�e !!°ZCC. -I--- - �
M.L.I."' l 1 ..........................