HomeMy WebLinkAboutApp-Permit-Compliance it.4.
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THE COMMONWEALTH OF MASSACHUSETTS ...
BOARD OF HEALTH
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Permission 's ereby granted l -
Permissions
to Construct ( as I ivi9loualneSe age Dis• isal System
Cod :
Dat
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as shown on the applicatio for D sposal rks C nstruction Pe NO/
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IL: of Health
DATE 1O,) 2'. /
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THE COMMONWEALTH OF MASSACHUSETTS
BOARD OF HEALTH
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Appi ratinn fur ilisposal lig orks Clluntu#rixttiun Permit
Application is hereby made for a Permit to Construct (— or Repair ( ) an Individual Sewage Disposal
iirt System at:
...... �� cation ddre�s or Lot No.
a riC , 4yr r - �c.� /lq Address d-�. i..1 »
Installer Address
Type of Building Size Lot 4-"° Sq. feet
Dwelling—No. of Bedrooms -a--- Expansion Attic ) Garbage Grinder ( )
a Other—Type of Building No. of persons Showe
Other fixtures
4 ( ) — Cafeteria ( )
W Design Flow 's gallons per person per day. To . ily flow J # gallons.
W Septic Tank—Liquid capacity..&vstallons Length.$. Width_. *"-Jo Diameter...,.5__ Depth
th
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Z —No. 2- - Width..... " Total Length.../.' Total leaching ar,...4g_al......fasep
e ag i No Diameter Depth below inlet . Total leaching ar, sq. ft.
z Other Distribution box ( ) Dosing tank ( )
I-1 Percolation Test Results Performed by Date ,..,
1-4 Test Pit No. 1 .t - minutes per inch Depth of Test •'t Dep.h to ground wa er '- - '
fs. Test Pit No. 2 minutes per inch Depth of Test Pi Dept to ground wa. r
a _ _...
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o Description of Soil 3' .l.072 vze.d- P....: '.-...ado--.✓:...!.-�1-11.t!.1
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V Nature of Repa s or Alterations— nswer when applicably
Agreement
The undersigned ees to install the afored' ribed Indi idual Sewage I isposal System in accordance with
the provisions of TITL ,5 of the State anitary Co.- —The un ersigned further agrees not to place the system in
operation until a Certificate,of Compliance has been_ :d s y the o o a .�
Sign /
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Application Approved By ate
�, P/ Dat
Application Disapproved for the following re ons:..
��...- Dau
Permit No 1 ✓ .... Issued.».-..111/41)61/N ....»......
THE COMMONWEALTH OF MASSACHUSETTS
BOARD OF HEALTH
OF .
Trrtifutt#r of flumpi unrr
. THIS IS TO CERTIFY, That the Individual Sewage Disposal System constructed ( ) or Repaired ( )
by
Installer
at
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
THE ISSUANCE OF THIS CERTIFICATE SHALL NOT BE CONSTRUED AS A GUARANTEE THAT THE
SYSTEM WILL FUNCTION SATISFACTORY.
DATE Inspector