HomeMy WebLinkAboutApp-Permit-ComplianceNo. L> —IGS FEn........L...
THE COMMONWEALTH OF MASSACHUSETTS
BOARD OF HEALTH
.....�. -S l..V�:...... OF ... ....V.\ ..."] .........................._...... ........
� �1utttion for Dioiaosal Marks Tonatrnrtion Famit
Application is hereby made for a Permit to Construct ( ) or Repair ( Cl-an'Individual Sewage Disposal
System at: )_ `St
_ i/��f f?uz.}.....i� ............................... ...............:D ....s f.lha'�Y.tcx }.................
............. ••- or Lot No
- Location. Address
..........`.1.. Y: s ..... ............sr .. ........................................._.....
.............
Owner Address
......� It �.:..G ✓11 u„..x ..... ... P .ra.. ...4sr............IM .4........
Installe Address
Type of Building Size Lot ............................ Sq. feet
Dwelling — No. of Bedrooms....3 ...... ............................Expansion Attic ( ) Garbage Grinder ( )
Other—Type of Building ............................ No. of persons Showers ( ) — Cafeteria ( )
Otherfixtures ..................... -......... .......................... ............................. ..............................................................
Design Flow.............................gallons per person per day. Total daily Row....;<..;r..a....................... gallons.
Septic Tank -j -Liquid capacity gallons Length.. .............. Width ................ Diameter................ Depth ................
Disposal Trench — No ..................... Width.................... Total Length.................... Total leaching area .................... sq. ft.
Seepage Pit No......./........... Diameter ....... {.O.L. "Depth below inlet ...... (g.l....... Total leaching area..................sq. ft.
Other Distribution box ( ) Dosing tank ( )
Percolation Test Results Performed by.......................................................................... Date ........................................
Test Pit No. I................minutes per inch Depth of Test Pit.................... Depth to ground water .....................
Test Pit No. 2................minutes per inch Depth of Test Pit.................... Depth to ground water........................
Description of
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Nature, of Repairs or Alterations — Answer when applicable.... d-_f�1 L- ......
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The undersigned agrees to install the aforedescribed Individual 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
i operation until a Certificate of Compliance
.- - -• .n issy. btrdof ealCth/.
. ._ .
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.i r.�
„Signe...��
-----------------....................................... D«APPlication Approved By....?1_1_0_1
Application Disapproved for 114ireasons:............................. .............----........-----••-------......-.._.............
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............................................................................................----•...... ............................. -..........................
Permit No........ L.1 ..—c k ._ .................._. Issued ..........._`� �.... ......
••------• Date
~ THE COMMONWEALTH OF MASSACHUSETTS
BOARD OF HEALTH
...._�...� {..},d:, -.t.4.^.`...:........ OF.....:^T..(,F.��o.t.Z:.e:}:9.;.+..C.Sv.:rn.....................................
Trrtifiratr of Tomithau rr
THIS IS TO CERTIFY, That the Individual Sewage Disposal System constructed ( ) or Repaired (X4)
I 4 I Installer
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masbeen stallsnacc---- 'htiP• •ofTITLE 5 of
fThe State Sanitary
iittar y Code as described in the
application Disposal V -Constructiontion Peet ...
dated. ..... L.. ... .,.. ......... ......
THE ISSUANCE OF THIS CERTIFICATE SHALL NOT BE CONSTRUED AS A GUARANTEE THAT THE
SYSTEM WILL FUNCTION SATISFACTORY.
T%A. P. f" - [ t r ----- Inspector .• --`—'- -->....-- -...-.': ... ..1: .