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HomeMy WebLinkAboutApp-Permit-ComplianceNo.S ............. THE COMMONWEALTH OF MASSACHUSETTS _ BOARD OF HEALTH ........ OF...........y t� i�/%rl ....................... Appliration for Disposal Works Cnoustrnrttnn fermi# Application is hereby made for a Permit to Construct (04-)- or Repair ( ) an Individual Sewage Disposal System at: J..`l ! - .' t� .9��`7��c�,l i`------------------------•---- ........_. .. .......MAP.-. �Cz 1. Gr�T/ _........... ......-----•....... .__.. ----- Location - Address / - or Lot No. /� ----------------------------- c/ ..... .-=--- O er Address = ---•-------•................................... ---.......:_Z. --..... ------------- ------- Installer Address d Type of Building Size Lot_.. �t�_ :2.........Sq. feet OtherDwelling in Type Building ...........................................Expansion Attic ( ) Gar04 bage Grinder ( ) g— yp ............................ No. of persons ............................ Showers ( ) — Cafeteria ( ) �Other fixtures ----------------•.--•----___-_. _ . W Design Flow ......... �'-----------------------gallons per person per day. Total daily flow__....._.._.. �.�----__._._..._.._gallons. WSeptic Tank — Liquid capacity -Z gallons Length --- IQ -tel Width-_ - Diameter ................ Depth. x Disposal Trench — No . .................... Width .................... Total Length .................... Total leaching area -------------------- sq. ft. Seepage Pit No ------ /'_........... Diameter-___ P..fr Depth below inlet----. Total leaching area._ 7 .... sq. ft. Z Other Distribution box ( ) Dosing tank ( ) _ .may '-' Percolation Test Results Performed by.-' ---�L = --- -----=--•------ Date_. �� .. d / �C J --•--- aTest Pit No. l�.�tw_ .u��' minutes per inch Depth of Test Pit ------ .... Depth to ground water! ......1�.MA'* (r4 Test Pit No. 2................minutes per inch Depth of Test Pit ........... :-------- Depth to ground water ........................ Pd--------•---------------------------------------•-•------------------------•'-•-•---......----............................................................... O Description of Soil....J� = ©��...1 j i? M 4 3l3 - '5" f�- �� !�? J r✓f " ......................... Nature of Repairs or Alterations — Answer when applicable_____. ----------------------------•-•--••-------•--_ •-_ • •--•-_ •--_----••--•_----•• _•--•-• ••......-----•--- •_• _-- Agreement : The undersigned agrees to install the foredescribed I the rovisions of p ','-T 5 of the State Sani ry Code — Th operation until a Certificate of Compliance ha been issued by Application Approved By..... W.:. Application Disapproved for the PermitNo --------------------------------------------------------- Sewage Disposal System in accordance with ned further agrees not to place the system in of he th. .. / at ........Date Date Issued-------------------------------------------------------- Date THE COMMONWEALTH OF MASSACHUSETTS BOARD OF HEALTH .......................................... OF ..................................................................................... Trrtifiraldr of Toutplinnrr THIS IST RTI FY, That the Individual Sewage Disposal System constructed (V ) or Repaired'(. ) b(. (�--------- - -------------------------------- ----- ----- --- y-------------------j--......-' �� nstaller, 1 e f ._ % . . at-------------'------�' G �f ------'--�--�--------- �� has been installed.in accordance with the provi ions of TI` IF Sof The State Sanitary Code described in the application for Disposal Works Construction Permit No. -.2-6). -.4-.. ......... dated ....... __.f y (J .................. THE ISSUANCE OF THIS CERTIFICATE SHALL NOT BE CONSTRUED AS A GUARANTEE THAT TIME SYSTEM WILL FUNCTION SATISFACTORY., DATE................................................................................ Inspector