HomeMy WebLinkAboutApp-Permit-Compliance` qt
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THE COMMONWEALTH OF MASSACHUSETTS
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BOARD OF HEALTH
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...... ..` .. .✓..�Y..-...... OF...... ..-�-------------------
Appltration for Disposal Works Tons rur#'ton Prrmit
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is hereby for Permit to Construct Repair ( ) Individual Sewage Disposal
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Application made a (1r) or an
stem at:
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or- Lot No.
%L ation - A �ressy(j/j (j
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}���.`�`./� Address
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Installer Address l q �} 3
Type of Building Size Lot ..... ................Sq: feet
Dwelling —No. of Bedrooms...............3_ .............. ........ E
PL4
Other — Type of Building ...--- No. of persons ....._... �! ............... Showers(--�"--'Cafeteriart--t—
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Otherfixtures -------------------------------•---------•------------.----------------------------------••--------------------........_............_.........._------
Design Flow ..................... �-------- gallons per person per day. Total daily flow ......... �..�._....-....._..�lonss.. if
WSeptic
Tank — Liquid' capacity.14.eagallons Length___ 1--_ &.. Width_'-..._._.._ Diameter ................ Depth.._......
x
Disposal Trench — No. ---_-------------- Width .................... Total Length .................... Total leaching area .................... sq. ft.
Seepage Pit No .......... ....... D'ameter........ _ o.___ Depth below inlet ....... k......... Total leaching area... 1�2.a.sq. ft.
box Dosing tapl
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'-'
Other Distribution ( _
Percolation Test Results Performed .................. Date._
aTest
Pit No. 1---45L-2--minutes per inch Depth of Test Pit...I. -z--.t-... Depth to ground water... 1...Z......."�`�
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Test Pit No. 2 ........ `---minutes per inch Depth of Test Pit :__.......e e_... Depth to ground water....._..._ .._..._._
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-----------------............................................................. --------------- ---
Description of Soil ......_...%---A-_a...--.?�.�----•-�'-=........ c ..................................................
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.........................................................
UNature
of Repairs or Alterations — Answer when applicable................................................................................................
---•-------------------------------------------------------------------•--------------....------------......------------------------------------------------------------------------------------------.
Agreement:
The undersigned agrees to install the aforedescribed Individual Sewage Disposal System in accordance with
the provisions of TITLE. 5 of the State Sanitary Code — The undersigned further agrees not to place the system in
operation until a Certificate of Compliance has been is e by the board o health.
Signed -•------- .._._.
Application Approved By.^�,' _._`1`a�c--------•---
Date
Application Disapproved for the f olowing reasons----------------------------•---•-----------------------------------------------------------------.._......-•----
-----•-----•-••--•--------•-------------•------------------------------------------•-----.---------------••----•--•-------•-•-•--------------------------.........------------....
Date
Permit No .... ��` -� Issued ------......--/ -�` -------------------
Date
THE COMMONWEALTH OF MASSACHUSETTS
BOARD OF HEALTH
........77_va.�- ..........OF....... .r- ...... ®.r .. `i....................
Trrtffirate of Tontliltanrr
THIS IS TO CERTIFY, That the Individual Sewage Disposal System constructed (�r Repaired ( )
by-----------------------------------------------------------------------•--•---------------------------------------• ---•---------------------------------------------•---------------•---------
all
at��''`� �� r l� "•i--"------- ----•--------------------------------------------------------••---•-----------------•---------------
has been installed in accordance with the provisions of TITLE 5 of The State Sanitary Code as described in the
application for Disposal Works Construction Permit No.____c1� == _1` �`"_........•....... dated ___...,-.--ef" ...................
THE ISSUANCE OF THIS CERTIFICATE SHALL NOT BE CONSTRUED AS A GUARANTEE THAT THE
SYSTEM WILL FUNCTION SATISFACTORY.
DATE....................................•-----.............-----••-•--.....------... Inspector.