HomeMy WebLinkAboutApp-Permit-ComplianceNo. 7. Fxx....... 5—
THE COMMONWEALTH OF MASSACHUSETTS
BOARD OF HEALTH
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Appliration for Disposal Works Tonstrurtion 1hruti#
Application is hereby made for a Permit to Construct ( ) or Repair (J( ) an Individual Sewage Disposal
System at
...?.1..�.�.�.�.� ..�'.as ma .......... ......................W. ._- �- ......................
Locat on -Add . .l_ � Vis----------- ... `-�...
or Lot - o.
Owner..........................................
Addre s
.-Ala_.. c a .................. ....-- - - ._........ 350 !_ . ... r :,.....Was.. , ldr rno --....................
Installer Addres
Type of Building CC�> Size Lot ............................ Sq. feet
Dwelling—No. of Bedrooms ............................................ Attic ( ) Garbage Grinder ( )��r
Other — T e of BuildingNo. of persons ............................ Showers — Cafeteria `�S�
Otherfixtures-----------------------------------------------•----.........---------------------------------------------------.......--••--------••---•------------.
Design Flow............................................gallons per person per day. Total daily flow ............................................ gallons.
Septic Tank — Liquid* capacity ------------ gallons Length ................ Width ................ Diameter ---------------- Depth ................
Disposal Trench — No ..................... Width .................... Total Length .................... Total leaching area .............--....sq. ft.
Seepage Pit No ..................... Diameter .................... Depth below inlet.................... Total leaching area .................. sq. ft.
Other Distribution box ( ) Dosing tank ( )
Percolation Test Results Performed by .......................................................................... Date ........................................
Test Pit No. 1................minutes per inch Depth of Test Pit -------------------- Depth to ground water ........................
Test Pit No. 2................minutes per inch Depth of Test Pita................... Depth to ground water ........................
...----•--------------------------------------------•-----------•---------------................---------------------..............---......................
Descriptionof Soil ........................................................................................................................................................................
.••--••-----•--------••-•--------------�................................................... I -----------------------
0.e
The undersigned agrees to install the aforedescribed Individual Sewage Disposal System in accordance with
the provisions of TITA IE 5 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 the board of health.
Sied---,P�.......................................... ..%-4- •.314.02...._ ....
ate
ApplicationApproved By... ..... .......................................................................... _ _.__._._ ��.�/_...--•---•--
Date
Application Disapproved for the llow%ng reasons- ............... •.......................................................................................... _--
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L Date
Permit No...... - ....--•-------. Issued..............1' lfjf/ .�..................
ate
PiL y� THE COMMONWEALTH OF MASSACHUSETTS
BOARD OF HEALTH
h(� l c,,:::?r:..................OF. c,.r:.�2zi3�.......................................................
Trr#ifb of (%utplinurr
HI �S TO CERTIFY, That the Individual Sewage Disposal System constructed or Repaired ( )
bY-:1.... - -.............---......._ ..
.............................................. .............•--.-�- ........ _
---..-•.........
r -- Installer
i i�J TC w� c)1n�x ' E'�Gi� �"� I
has been installed in accordance with the provisions ofTj, SLE 5 of The State Sanitary; odea des ibe the,..
(} ...........
application for Disposal Works Construction Permit No. Z?------� _ S ................... datefi'�
THE ISSUANCE OF THIS CERTIFICATE SHALL NOT BE CONSTRUED AS A .. U NTEE THAT THE
SYSTEM WILL FUNCTION SATISFACTORY.
DATE
------Inspector_.,_,. rt y;FF �' .L_ �� ` I.9 rtr ..'i�1G ......................
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