HomeMy WebLinkAboutApp-Permit-Compliancey.... ............—
No.0------ -
THE COMMONWEALTH OF MASSACHUSETTS
BOARD OF HEALTH Ocb A4P R(V%/1I
G Ws'1........... OF.......... C -/-- ----------------------------------- /I'(''.ri '(3,9/Z.'
,5q ApPratiou for Utspu,aal Vorkfi Tomitrur#ion jkrufit
Application is hereby made for a Permit to Construct ( ) or Repair ( ) an Individual Sewage Disposal
System at: �� f`
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Locat' A dyes �f� /V��'T?, /`7Q / o_sN_'
.......--... •- 6
Address
-......
nstaller Address ���Jk
Type of Buildi7 // Size Lot. -__.__.a.__._7___ ..... Sq. feet
Dwelling —No. of Bedrooms -__--___---_ T .........................Expansion Attic ( ) Garbage Grinder ( )
Other — Type of Building ............................ No. of persons ............................ Showers ( ) — Cafeteria ( )
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 .........-_.-y.._._ Total leaching area .................... sq. ft.
Seepage Pit No ------ I.......... Diameter... Depth below inlet ...... ra_........ Total leaching area.:?5;9 .;F�_sq. ft.
Other Distribution box (}C) Dosing tank
Percolation Test Results Performed by__%--� �- C= '----------- Date .... ---------
Test Pit No. 1 G_...minutes per inch Depth of Test Pit ----- j_........ Depth to ground water__lt-�?!<___.
Test Pit No. 2................minutes per inch Depth of Test Pit ............... _---- Depth to ground water ........................
-------------------- ;_ ............
..i�a��Description of Soil --- 0-._e44 .
Zl� - � `7� rr� ----- .
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Nature of Repairs or Alterations — Answer when applicable_-
Agreement:
The undersigned agrees to install the aforedescribed Individual Sewage Disposal System in accordance with
the provisions of iTTLE, 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.
Signed---- -----•-----•----•---- .......
Application Approved By---------- ��-------------------•--- /-
Application
0�
Disapproved for the following reasons: _
Permit N
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Date
Issued------------------_-- --------------------------------
Date
THE COMMONWEALTH OF MASSACHUSETTS
BOARD OF HEALTH
.......................................... OF .....................................................................................
Trtifiratr of (1 outpliatta
THIS IS T,0yCERTIF�yThat the Individual Sewage Disposal System constructed (4) or Repaired ( )
by........................ ......--.......---.....---- .. �srG------ ..........-- -----------•-----•----------..----.-------------------
nstaller -
............. Z
has been insta ed in accordance with the provls>oi of TI ± I " > of The State Sanitary Code des ribed in the
application for Disposal Works Construction Per It No.__..��.____.._._. dated__... r�...__.� C?_..___._._.
THE ISSUANCE OF THIS CERTIFICATE SHALL NOT BE CONSTRUE® AS A G ARA Tl MAT THE
SYSTEM WILL F"CTION SATISFACTORY.
DATE........ ... ----------------------------------------- InsP :.-------------------