HomeMy WebLinkAboutApp-Permit-ComplianceNo._IL. .. ¢¢.1
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THE COMMONWEALTH OF MASSACHUSETTS I ��
BOARD OF HEALTH
............. OF........Y_..
Appl ration for Elisposal Works Tonstn uffutt f rrntit
Application is hereby made for a Permit to Construct ( V) or Repair ( ) an Individual Sewage Disposal
S stem at
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' Address
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Owner
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Installer Address r.y
Type of Building // Size Lot .... _./ _.._i. 2 O U_.Sq. feet
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aDwelling — No. of Bedrooms .............? ........................... Expansion Attic (NO) Garbage Grinder (AJO)
p., Other — Type of Building ............................ No. of persons ............................ Showers ( ) — Cafeteria ( )
Other fixtures 4rXa, W;A':t-•-----_----"--•--"---------------•----"""-".....
77
W Design Flow........ �./... ...............•._".-.-.gallons per person per day. Total daily flow .................. _.._...................... gallons.��
WSeptic Tank —Liquid'ca.pacity_loO-0gallons Length_.0-_!Vi.. Width..- Diameter ................ Depth...
x Disposal Trench — No. -------------------- Width .................... Total Length .................... Total leaching area ................... sq. ft.
Seepage Pit No ..................... Diameter.................... Depth below inlet .................... Total leaching area .................. sq. ft.
Z Other Distribution box (x) Dosing tank ( )
Percolation Test Results Performed by..... .._.cJ....Q_...6/�E R _...INC.:.._. Date ...._.�......
aTest Pit No. 1.. <..2 --minutes per inch Depth of Test Pit......9 Z �- Depth to ground water ............ ........
Test Pit No. 2............."..minutes per inch Depth of Test Pit .................... Depth to ground water ........................
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Description of Soil ........ .
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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 TITLE5 of the State Sanitary Code — The undersigned further agrees not to place the system in
operation until a Certificate of Compliance has be n issu by t board of health. .i
Signed._._
D e
Application Approved By ----- �-�.�G.I, L�s1��...��---•--------------------------------------- -•--j Date ---••-
Application Disapproved for the following reasons----------------•-•-----------------•--...-----....---------•---•--------•---•--------....-----•---•---•-•....._
...............................^-•-----......j.'...----•-----------.....--•---------..._..---"----------------------•--------q...I.------.................................------
Date
PermitNo.... r..... . !---•--.....-----•-----. Issued ..... Date S .........................
THE COMMONWEALTH OF MASSACHUSETTS
BOARD OF HEALTH
.......................C�' ............... OF ....y..............................................................................
Ternfirate of Tomplittnrr
THIS IS TO CERTIFY, That the Individual Sewage Disposal System constructed (fir Repaired ( )
by_.�-�i.,e.!bk1-e�deQ-- - •• -- -
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Installer
at....1dt..... .................................... ----•----•---••------......------....._._...--------•---...------..........•.....__...--....._
has been installed in accordance with the provisions of TITLEE 5 ofThe State Sanitary Coe as described in the
application for Disposal Works Construction Permit No 0:-_ 4_4_ 1 .............. dated.......7i - j._�1 ..............
THE ISSUANCE OF THIS CERTIFICATE SHALL NOT BE CONSTRUED AS A GUARANTEE THAT THE
SYSTEM WILL FUNCTION SATISFACTORY.
DATE-------------------------------------------------------------------------------- Inspector.