HomeMy WebLinkAboutApp-Permit-ComplianceNo...... �.
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THE COMMONWEALTH OF MASSACHUSETTS
BOARD O,,F/ HEALTH
.-----...OF............L/GG Q.. .....................................
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, r lint ivat
for Uhipaii al Works Tutt uurtiou rruttt
Application is hereby made for a Permit to Construct (X) or Repair ( ) an Individual Sewage Disposal
Sys em at:
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OwnAddress
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— InstaAddress
d Type of Building Size Lot-.-� �''_-Z!�429-__-Sq. feet -.6
Dwelling —No. of Bedrooms ............ ..4 ......................... Expansion Attic ( ) Garbage Grinder ( )
Other — T e of Building No. of persons ............................ Showers — Cafeteria
a Other fixtures -------------------------------- -
W Design Flow............................................gallons per person per day. Total daily flow ........... ................. gallons.
WSeptic Tank — Liquid capacitya'Oa--gallons Length ................ Width ................ Diameter ................ Depth ................
x Disposal Trench — No_ ____________________ Width .................... Total Length .................... Total leaching area .................... sq. ft.
Seepage Pit No -1 Diameter-__ --- Depth below inlet ...._ . �F . _....-_-- Total leaching area_:4!1 +--;F!�. � sq. ft.
Z Other Distribution box ()C) Dosing tpLnk ( ) _
Percolation Test Results Performed by__?..%l/----=•----- Date ...... --- ------
aTest Pit No. L<24 Z __..minutes per inch Depth of Test Pit ---- 'Z ' ._.___ Depth to ground water...A—.) 2ca,
Test Pit No. 2................minutes per inch Depth of Test Pit .................... Depth to ground water ........................
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Description of Soil �� �� ` G cL a--'-�'-/-•---------------•--•-----------------•-------•--------------•--•----•-••-----------.
---•-------------------•-- 4 �f / 1�t �4? _5�� !?4r---_----•---- •------------------------------------------•----
----•--------------------------------------------------------------------------------------------------------------------------- --------------••--------•-•-••--------------•------------------•------
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
the provisions of :? IEE 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.
ined-------------------------•-•-------_----•--------------------------------•---• .---------------•---•------
D e
Application Approved By ............. ` --------------------------- .�, Dat----------
� Date
ApplicationDisapproved for the f s. --------•-----•---------•--•--•---•------------------•----•---•--•---•---------•----••-----------•---•-•--------
--•-------•---•--•............•-----•----- ----------•--------•----------•'Da......------•••-
PermitNo --------------------------------------------------------- Issued .......................................................
Date
THE COMMONWEALTH OF MASSACHUSETTS
BOARD OF HEALTH
.......................................... OF .....................................................................................
Trrtifiratr of Tautptittturr
THIS fS—TO CERT, That the Individual Sewage Disposal System constructed (`ti:) or Repaired ( )
by .................. �_, --- 4_AK19`v::-..---------••--•----irmit
....... •-•- -------•------------•-----------------•------------•--------------
i / Install /
at - = `< !
-- -�----•-------�--- -----
has been installed in accordance with the prof TIT TR 5 of The State Sanitary Code " described in the
application for Disposal Works Construction No..� ...r_..e2�...__....... dated_....�-__r_::...s-t'___U.............
THE ISSUANCE OF THIS CERTIFICATE SHALL NOT BE CONSTRUE® AS A G AR, TEE HAT THE
SYSTEM WILL FUNCTION s S TISFACTORY.
DATI. -
Inspec<o) - -----•------------
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