HomeMy WebLinkAboutApp-Permit-ComplianceTHE COMMONWEALTH OF MASSACHUSETTS
•`{'_ BOARD OF HEALTH
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Appliratiun for %qpuual Wuxku Towitrnrfiun rrrmit
Application is �h eby made for a Permit to Construct ( X) or Repair ( ) an Individual Sewage Disposal
System at: kJolk-15 N p/
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Y- L9cation - Address qr Lot No.......
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........%:.[..�..1.2.:?a.L_<<............ ........._:�...�??.:!::...a....�::?.+1.
_ Owncr , . r .. Address
Instailsr1, e11 Address
Type of Building W t/J� l Size Lot ....tC_.G.'.c3...-..Sq. feet
Dwelling — No. of Bedrooms._......_'..............................Expansion Attic ( ) Garbage Grinder ( )
Other—Type of Building ............ ................ No. of persons ........................._ . Showers ( ) — Cafeteria ( )
Otherfixtures ................... --..._...............----.----....-----....................-.......__.---------.------.................................
Design Flow........, 1 —5. .......................gallons per person per day. Total daily flow........ -.s.t ......................gallons.
Septic Tank—Liquid capacityl,.S t!gallons Length___. ?......__ Width___ ...:..... Diameter ................ Depth....'......
Disposal Trench -- No. ...... ___ ........ Width .................... Total Length ........... ........ . Total leaching area .... ................ sq. ft.
Seepage Pit No..... . I ............ Diameter ....... 6......... Depth below inlet ..... 6 ....: ...... .. Total leaching area ..... %zr.L:Z.sq. ft.
Other Distribution box ( ) Dosing tank ( )
Percolation Test Results Performed by ...... ....:.... ----.-._.........----..... Date .... _C_x-.....
Test Pit No. ]. ..1.....
minutes per inch Depth of Test Pit...... 4n... _. Depth to ground water....NN.t?.. -..
Test Pit No. 2................minutes per inch Depth of Test Pit.................... Depth to ground water ---- ............. .......
Description of Soil......---. 4 S:.ta:./...._Z' "
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 TITLE S of the State Sanitary Code — The undersigned further agrees not to place the system in
operation until a Certificate of Compliance has bee ' sued by the board of health,
t
Ign-% Grfl• 7
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Application Approved B / D��.
Datn
Application Disapproved for the following reasons: ................. .......................................... ...............................................
Permit
THE COMMONWEALTH OF MASSACHUSETTS
BOARD OF HEALTH
Date
Date
........... IA..?abl........... OFr..:f7`..i? .d/.,t:f rZ.-X.._/......................................
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Tintifiratr of tum rlittnrr
THIS IS TOY,7pat the Individual Sewage Disposal System constructed ( ) or Repaired
has been installed in accordance with the prov6fons of TITLE, 5 of The State unitary Code as described in the
application for Disposal Works Construction Permit No.,�,Z41
.`.�J .............. dated. f .:. ✓�...:...��r�
THE ISSUANCE OF THIS CERTIFICATE SHALL NOT BE CONSTRUED AS A GUARANTEE THAT THE
SYSTEM WILL FUNCTION SATISFACTORY.