HomeMy WebLinkAboutApp-Permit-ComplianceNo .... 7f 7-2 A_ FE$.... ........... ~
THE COMMONWEALTH OF MASSACHUSETTS
f.
BOARD OF HEALTH
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Appliraffou for Bi ipmaal Workfi Towitrurtiun Vrrmff
Application is hereby made for a Permit to Construct ( or Repair ( ) an Individual Sewage Disposal
System at
.....:�......®�I�.! ,/ !^!.7"....... �' "--_---•-•----•�f'r�`�� `�����------------------------- " er/ '_._T__...--•------------
L,oca�tion- Address ®j or Lot No.
............. .----� : F2".�i� Ns�/ j, _._.. �f ..................
...• ........................•............_Address
Installer Address
Type of Building Size Lot. ,,Y o . Sq. feet
Dwelling — No. of Bedrooms..- _ ..,,; _.•_.._........................ Expansion Attic ( ) Garbage Grinder ( )
Other
—Type of Building � i_:. 6~�_... No. of persons ... ..._.__ ___________ Showers Cafeteria ( )
Otherfixtures .......................... ......................... .......................
Flow ------ .............. ............gallons per•penstm per day. Total daily flow ----------- _• Ions. eL eq.
Septic Tank —Liquid capac t � _gallons ength_ �.-..._.. Width_____ �__. Diameter ................ y nth_.._-. � ��
_ - ,- . e
Disposal Trench — No. _•_•---------------- Width... -__y.._.__._._. Total Length___. ..._._....._ Total leaching area.._...: A f-_ q. ft.
Seepage Pit No.-___-..__.___-_-- D' meter-------------------- Depth below inlet .................... Total leaching area .........._ ��`eft.
Other Distribution box ( Dosing tank
Percolation Test Results Performed by .... ,,r.._.1T�th.1�.`..... Date_.___,.. �,l _:..
Test Pit No. ....... minutes per inch Depth of Test Pit.. v_._ Depth to ground ater...�S3c�_!u._s '.
Test Pit No. 2--._Z. ...... minutes per inch Depth of Test Pit.,/Y---------- Depth to ground waterer ®�'*!Z' �
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Description of Soil ---------c5 �,........ 1�/_ ....._...-..,t
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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 :IT -E 5 of the State Sanitary Code —The undersigned further agrees not to place the system in
operation until a Certificate of Compliance has beeeise y e b�roflth.
Signed,�..... -----------•--...--•-----•---................................
Date
Application Approved BY - ----•---••-----------•--.------•.
---------------------------------------
Date
Application Disapproved for the following reasons: ____-
Permit
Date
Issued.......................................................
Date
THE COMMONWEALTH OF MASSACHUSETTS
BOARD OF HEALTH
...................................... I... O F .....................................................................................
Tatifi atr of Toutpliattre
THIS IS TO CERTIFY, That the Individual Sewage Disposal System constructed ( ) or Repaired ( )
by...................................................
Installer
at--------------•-------------------------•----------•--------------•----------------------------------- -------------------------------------------------------------------------------._.-------------
has been installed in accordance with the provisions of TITLE; j of The. State Sanitary Code as described in the
application for Disposal Works Construction Permit No ......................................... dated ----------------------------- ...................
THE ISSUANCE OF THIS CERTIFICATE SHALL NOT BE CONSTRUE® AS A GUARANTEE THAT THE
SYSTEM WILL FUNCTION SATISFACTORY.
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