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HomeMy WebLinkAboutApp-Permit-Compliancea U a P4 W W Z a a w w U t NaX/_ -,1.. Fes$....... 77-ASO ^ChSO THE COMMONWEALTH OF MASSACHUSETTS �V ff ��j BOARD r,WHEALTH . OF........... ........ Appliratinn for Disposal Warks Tonotrurtion Frrutit Application is hereby made for a Permit to Construct (✓) or Repair ( ) an Individual Sewage Disposal System at w -.....G /Z' V.............g.................... T .7 9 ._.....-•------- W t L L I;kjtiop -Address V L O E> I S ^•-- or Lot No. ......7.......... ----------•------ . f_ -•-----•--------------•------•--------- Own r Address ------------ � -- . `............ ��= �' :�.n- O.VA---,------------------------ Installer Address + Type of Building Size Lot ... y 7..__ -..Sq. feet Dwelling —No. of Bedrooms..............Z.......................... Expansion Attic (NO Garbage Grinder {(40 Other — Type of Building -----___-_-------------- - No. of persons ........... ................. Showers ( ) — Cafeteria ( ) Otherfixtures-•--•---------------------•---•----•------------•--•--.••--------•------------------------•----•----------....-----••--•••-•--------•--•----....----•- Design Flow ............. ...................gallons per person ey «y. Total daily flowfl-------2.2.0...................•..gallon Septic Tank — Liquid' capacity.1QG...gallons Length........ Width._y.__/�._. Diameter ................ Depth._ Disposal Trench — No ..................... Width .................... Total Length......_....._._..... Total leaching area .................... sq. ft. r � Seepage Pit No --------- I---------- Diameter .... _J.2._..... Depth below inlet ....... Total leaching area --- 2.is q ---.sq. ft. Other Distribution box ( ) Dosing tank ( ) I u Percolation Test Results Performed by__ --_...i ... I_Ni �c.__..._. Date ...... S._�__.__.. i Test Pit No. 1._.4..z ... minutes per inch Depth of Test Pit...Depth to ground water ...... 11__________ Test Pit No. 2...__._._. --minutes per inch Depth of Test Pit ..... ........... Depth to ground water ------ 12-1 ......... # --------------------------r-- If --------- -- Y/------------------------------------- ---- Descrip`t74n of Soil - 3e'®P 5 fJ8 SOIL -D l /E�U/��J10 iV� S .p....-••-•........ G�-. fib....... TO�' �.....S.u,BS��.---- --- ---. ��c� ��.. �?�`�� ij�� -------- .S�-D------------------------------------------------------------------- ---------------------------------------------------------------------------------------------------------- Nature of Repairs or Alterations —Answer when applicable._..-.•......................................................................................... -------------------------------------------------------•---•------------------------•-•--------•-•------------------------------------------------------------------•------•---------•--•--------------• Agreement: The undersigned agrees to install the aforedescribed Individual Sewa isposal System in accordance with the provisions of TITLE 5 of the State Sanitary Code — The undersign q11 agree of to place the system in operation until a Certificate of Compliance has been issued by tthhe� boar o� cal - Si d. `''� . --1`x..... ---- •---•-•---- - � '. ....... �/,afscr _D Application Approved By.... •-- --- •--............ •.......................... ` .. Date Application Disapproved for the following reasons---------------•---•------------------------------•---------------------------------•--•-••----•--•----•---_..... -•-------------------------------------------------------•----------------------------.......------....-------------•••-------•--•-_---_._...----••-•-------••-----••-•--•---- •-------••---• .......... Permit No... ............................... Issued _..... 1._!,(Cl -.._----• . Date ...... Date THE COMMONWEALTH OF MASSACHUSETTS BOARD OF" HEALTH ':/..:..: .................. OF ..... ��............................................ Cprrtifirtate. of Toutplianrr THIS IS_TO. CERTIFY, That the Individual Sewage Disposal System constructed (v -)or Repaired ( ) byr .----------------------------------------------- 1 / Ipstaller i Jif. l`A / >y � /` at--•-•-•-----...---•--....... �---------------------•-` - = - =------••---•`•------•--------•••--••----------•-•-----•-•-----------••--------------•...- has been installed in accordance with the provisions of TIT p- ofrThe State Sanitary Code as/descr'bed in the i application for Disposal Works Construction Permit N .o.----....................... ............. dated__. ....... ___._ . ..................... THE ISSUANCE OF THIS CERTIFICATE SHALL NOT BE CONSTRUE® AS A GUARANTEE THAT THE SYSTEM WILL FUNCTION SATISFACTORY. P A TF T„ annrl-nr 12