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HomeMy WebLinkAboutApp-Permit-ComplianceTHE COMMONWEALTH OF MASSACHUSETTS BOARD OF HEALTH .............. ..............O F.........................------........--- ..... ... .Z ppliration for Disposal Works Tonstrur#tun thrutit Application is hereby made for a Permit to Construct ( ) or Repair an Individual Sewage Disposal System at: �4.. ,,Q. �L� 3 ........-. ..: ............. .. �..L.. -.. .....-- . -- ---......1..........-•----. o do - A r or Lot No. T ^'© ....................... . _..... . . ... ................. ....................-----------------------------------------------------------.........------. Owner n Address ...................................................... ......•... ------------------------•---•---.....-------------------•----------......--•-.....------......---- Installer Address Type of Building Size Lot ............................ Sq. feet Dwelling — No. of Bedrooms............................................Expansion Attic ( ) Garbage Grinder ( ) Other —Type of Building ............................ No. of persons ............................ Showers ( ) — Cafeteria ( ) Other fixtures ---------------------------------•----------- Design Flow............................................gallons per person per day. Total daily flow ............................................ gallons. Septic Tank — Liquid capacity ............ gallons Length ................ Width ................ Diameter__-__________.__ Depth ................ Disposal Trench — No . ........ ........... Width .................... Total Length .................... Total leaching area .................... sq. ft. Seepage Pit No ------_------------- Diameter .................... Depth below inlet.................... Total leaching area .................. sq. ft. Other Distribution box ( ) Dosing tank ( ) Percolation Test Results Performed by ........................................................... -------------- Date------ ................................. Test Pit No. I _______________minutes per inch Depth of Test Pit .................... Depth to ground water. ....................... Test Pit No. 2................minutes per inch Depth of Test Pit .................... Depth to ground water ........................ Description of Soil .................................. ................................ --•-----------------•----------•-----------•-......------------------------------------......--------------•------•- ................................................... Ir ---------------------•-----•--------••------------------------•--------------------------------•------------------- •-------------• . Nature of Repairs or Alterations —Answer when applicable---... -------- .............. ...'_....__..j�_ _ --------------------------------•-------------------------------------------------......---•-------------------------------------------------------•.----•--- Agreement: The undersigned agrees to install the aforedescribed Individual Sewage Disposal System in accordance with the provisions of TIT. of the State Sanitary Code — The undersigned further agrees not to place the system in operation until a Certificate of Compliance has been issued by the board of health. Signed...................................................................................... ................................ Date Application Approved BY............................ _ ' � = � e ........................................ Date 0 Cf:'o`''a ..... .., ....� Date Application Disapproved for the following reasons------------------------------------------------------------- -----------------------------------•-•-•-----•----- .....•--...•-------•-------------------------•--•-•••--•-----...-•---•-------•-----------•-----------•--•-------------------------••-----• ............................................................ Date PermitNo ......................................................... Issued ....................................................... Date THE COMMONWEALTH OF MASSACHUSETTS BOARD OF HEALTH .......................................... OF ..................................................................................... fiff uEnttftratr of Toutpltanrr THIS IS TO CWIJ?/-;That the Individual Sewage Disposal System constructed ( ) or Repaired bY------------------,.: t; . , , �. -------------- . --------------------------------------------------------------------------------------- f st ter f� , F = -- -------- at-------- v f... -•--•------ �...f-------------- - ------ - t has been installed in accordance with the provisions I'LL j ofhe State Sanitar Code /s�scpPbed�in the P Yapplication for Disposal Works Construction Permit 1 0._. :__,....___..._ ---- dated._..__________,�./�...__._. THE ISSUANCE OF THIS CERTIFICATE $HALiNOT BE CONSTRUED AS A GUA ANEE THAT THE SYSTEM WILL FUNCTION SATISFACTORY. DATE................................................................................ Inspector