HomeMy WebLinkAboutApp-Permit-ComplianceTHE COMMONWEALTH OF MASSACHUSETTS
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BOARD OF HEALTH
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Appliration for Dioposal Works Tomitrurtion 1hrmit
Application is hereby made for a Permit to Construct or Repair (
0 - 'System at:
c),A
. .............................. I . . .... _4� ... e ..............
.......... ........... 2f..V
) an Individual Sewage Disposal
Type of Building
Dwelling — No. of Bedroo
Other —Type of Building
+1, , r, + .
Address
............
... . . . ............
Address a '
Size Lot..,4j
..---Sq. feet
;ion Attic Garbage Grinder
... /^/ ...... ------- Showers ( ) — Cafeteria
------------------_ .................... ...-------------f---------------------------------- ..... --- - --- ----------------------
M ...........
Design Flow______________ .... -- --- -----------_------ Zallons �er person per �ay. Total daily Pow- ........ gallons.
- '_ --- I ......... A0 .
Septic Tank — Liqui��capp_acity�&Vallons 11 Length ____ -UQ.----- 9 -------- Width ... C I Diameter________________ Depth_____.._____.__.
Disposal Trench — No . .................... Width_._ ... ............ Total Length .............. / ... /Total leaching area_._........... sq ft
Seepage Pit No ..... -f. Diameter.......) ------- Depth below Total leaching area. ..sq.* ft.'
Other Distribution box DosingAa
nk
Percolation Test Results Performed by..
.. .... . ................. . ate ...... .............
Test Pit No. I ................minutes per inch Depth of est Pit________---_---._.-- Depth to ground water......._.
Test Pit No. 2 ................minutes per inch Depth of Test Pit..._..........__.... Depth to ground water./4
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Description of Soil----------- ....... .. .. ..........
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Nature of Repairs or Alterations — Answer when applicable...................................................__ ..............
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Agreement :
....
Agreement:
The undersigned agrees to install the aforedescribed Individual Sewage Disposal System in accordance with
the provisions of TITLE 5 of the State Sanitary Codes?- The undersigned further agrees not to place the system in
operation until a Certificate of Compliance has bee iss-tfed by the board of health
Signed-_
r....D..a..t.e.
..............
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- -----------
Application Approved BY .............. ... . .................... - - - Date
....................
Application Disapproved for the following reasons:...._.....
......................................................... ......................................................................................................... .....................
Date
PermitNo ......................................................... Issued .......................................................
Date
THE COMMONWEALTH OF MASSACHUSETTS
BOARD OF HEALTH
....................... . ......
...... ..... 0 F ......... ....... ./ . F`.......1.. ./�
Trrtffirab of Tomptiatta
THIS IS, TO CERTIFY, That the Disposal System constructed or Repaired
-1-- /1, 4
by -------------------
:1� ......... ------------------- ---------------------------------------------------
.. ........ )911 installer
A-
. j( - ......................... ...........................................
at ............. ........... .................. ................. e ...... ------------
has been installed in accordance with the provisions of TIT
LEE 5 ' of The State Sanitary Cod as de§cribo in the
application for Disposal Works Construction Permit No ... ....... . ........ w .............. dated___ - 7_ -7 ..................
THE ISSUANCE OF THIS CERTIFICATE SHALL NOT BE CONSTRUED AS A GUARA TEE THAT THE
SYSTEM WILL FUNCTION SATISFACTORY.
DATE .................... 2. v 4 ( 7
........................................................... Inspector ........ ------- ........ .............. ...............