HomeMy WebLinkAboutApp-Permit-ComplianceNo. .�.' / Fps....
61 ,
THE COMMONWEALTH OF MASSACHUSETTS
�-- BOARD PF HEALTH
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App ira#ion for Disp.aii al Workii Tonotrnrtinn jJamit
Application /is hereby made for a Permit to Construct (V) or Repair ( ) an Individual Sewage Disposal
System at 4- L/ -" �v M,4 P q� l (_:. �'�r......................
.....-------•---- °.................. --•---------_.....-•-----------...._..-----••---••-------- _
-------------------- _ --
� �^ cation - s .�- _ or Lot No. �/
.. 4_�. i i •c<<f `7 � 4%� �•-• ,`"'. � ress� �----- �L. l� - � ----
Owner
---•-------•----••------- ...e..---•----------------------------'----------•-------•----------------•-------••-•---.._Add...--------------...............-----^•-^---•-
Installer Address
Type of Building Size Lot ............................ Sq. feet
Dwelling —No. of Bedrooms.........................................Expansion Attic ( ) Garbage Grinder ( )
Other — Type of Building ............................ No. of persons ............. _.............. Showers ( ) — Cafeteria ( )
Otherfixtures--------------------------------------------•---•---...-----------------------------------------------------------.....-............._...._..--------•
Design Flow............................................gallons per person per day. Total daily flow __-_?4 41.P ............................ gallons.
Septic Tank — Liquid capacityLN�19_..gallons Length ................ Width ................ Diameter ................ Depth ................
Disposal Trench — No- -------------------- Width-._____ .___.._____ Total Length ..___...._ Total leaching area.___.._____ sq. ft.
Seepage Pit No .... I--------------- Diameter..!Z_� Depth below inlet-.-.-..... �_.... Total leaching area_. 3��:_�sq. ft.
Other Distribution box (. 0() Dosing tank ( )
Percolatior> Test Results Performed by._ 6.4,C,•,✓._.Zf.1i-i�_-----1 ......... Date. JLA.,y ... L,__ _.
Test Pit No. 1 __` ---- minutes per inch Depth of Test Pit_l. �............. Depth to ground water.IVQ._.___� -__.
i
Test Pit No. 2: ---------------minutes per inch Depth of Test Pit .................... Depth to ground water ........................
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Descriptionof Soil ----•-7j ......... 2 t , --- --- `- L'-------------••-------•-----•---•---•-------------........................
.....-•-------••-----•-•----------•--•---------------•--------------•----•----------------'--•---•----- --•--:-------------•------••-------------------•-•---------- - ------------
Nature of Repairs or Alterations — Answer when applicable....................................•......_.._.............____._..........._..___._.._..__....
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Agreement:
The undersigned agrees to install the aforedescribed Individual Sewage Disposal System in accordance with
f'1T �:1' �-•
the provisions of T � 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.
Application Approved By
Application Disapproved for the following reasons:---
Permit
easons:___
Permit N
Issued -------------------------
Date
THE COMMONWEALTH OF MASSACHUSETTS
BOARD OF HEALTH
Date
................................. OF .....................................................................................
tiirriifirtt�r of (�.ant��i�tnrr
THIS IS,%T-,,d CTIFY, That the Individual Sewage Disposal System constructed) or Repaired ( )
Installer
. ---
at............----------`-- -----------------------------
has been installed in accordance with the provisions of T :INSTRUED
State Sanitary � •P d in the
application for Disposal Works Construction Permit 1'o._
dated ------- _.../_ __.
THE ISSUANCE OF THIS CERTIFICATE SHALL NOT BE AS A A ANTEE THAT THE
SYSTEM WILL FUNCTION SATISFACTORY.
DATE-----------•---------------------------------------------------------------•---- Inspector.