HomeMy WebLinkAboutApp-Permit-ComplianceTHE COMMONWEALTH OF MASSACHUSETTS
BOARD OF HEALTH
1� ........................OF....
Appliration for Disposal Works Tonotrudion Frrmi#
Application is hereby made for a Permit to Construct ( ) or Repair ( ) an Individual Sewage Disposal
System at:
.........._1.................................. ____
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ion } ddres p. or Lot No.
...... ..... ..»... .f.[ _ A� kc! . . ....................................................................ress ^
...............---........._._................
---_... Add
�Iailer Address
Type of Building 2Size Lot ............................
Sq. feet
a Dwelling — No. of Bedrooms............................................Expansion Attic ( ) Garbage Grinder ( )
aOther — Type of Building ......"IO&Z _. No. of persons ............................ Showers ( ) — Cafeteria ( )
Otherfixtures ....-•----------------•----------.....----.....__.._..---------••--•••-•--••-•._.....--_..
W Design Flow ............................................ gallons per person per day. Total daily flow ............................................ gallons.
WSeptic Tank — Liquid capacity ............ gallons Length ................ 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 ( ) Dosing tank ( )
a Percolation Test Results Performed by.......................................................................... Date ........................................
Test Pit No. 1................minutes per inch Depth of Test Pit---_.----_-__-__-_-_ Depth to ground water ........................
f� Test Pit No. 2................minutes per inrha Depth of Test Pi. _-_--_-_-_---___- Depth to ground water ........................
x..........
Description Description of Soil ........................................................................-----------------------------------
..
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Nature of Repairs or Al s —Answer when lira le--••--...
�KDR
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Agreement:
The undersigned agrees to install the aforedescribed Individual Sewage Disposal System in accordance with
the provisions of LITI,L 5 of the State Sanitary Code — The undersigned further agrees not to place the system in
operation until a Certificate of Compliance has ben I ed by of health.
ed. .----•••....................... ------
Application
---- Application Approved By*'......... .... '.... ....................................................
Date
Application Disapproved for the following reasons: ......................................................................
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Permit No.. V .. 10------••--------------------•......
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..n Date
"Date
THE COMMONWEALTH OF MASSACHUSETTS V
BOARD OF HEALTH
!.�/..".:..!.............. ..OF......1Q..1 il........
(Irr#ifiratr of Toutplittnrle
CTIPS4S TO CERTIFY, That the Individual Sewage Disposal System constructed ( ) or Repaired (� )
CCX�l4VRTl.UG
by_... - /.....
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•••--------- ----•--••------%----------------•----
--•-------,-_y____--------•-------------------•-------•---___-----•--------_____--_------------_____-__---•---•--•------------
at .... _.J.�.LR?QuJ!! Installer
has been installed in accordance with the provisions of T T '' ` f The State Sanita y� . de dj d in the
application for Disposal Works Construction Permit No.�l<................... dated_- . __._ _._._._..____....
THE ISSUANCE OF THIS CERTIFICATE SHALL NOT BE ZSTRU D S A URANTEE THAT THE
SYSTEIroI L FUN ON SATISFACT Y.l!DATE.' � •----••-_ Inspector.....: 41� -----------------------