HomeMy WebLinkAboutApp-Permit-Compliance �
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TIiE COMMONWEALTH OF MASSACHUSETTS
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� BOARD OF HEALTH
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A licahon is hereb de for a Permit to Const:uct ) or Repair (� an Individual Sewage Disposal
System at: Y
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W Address
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� nstall<r Address
VType of Building Size Lot----------------------------Sq. feet
a.+ Dwelling—No. of Bedrooms............................................Expansion Attic ( ) Garbage Grinder ( )
Offier—Type of Building -_------------------------- No. of persons--.----.--.-------_--_--_ Showers ( ) — �eteria ( )
4 Other fixtures ------..... ....- --�--------------�------�-------- ---- ----� -----
--------------------�----------�-----------•-----�
W es�gn Flow-.-----_-----------------------------�lons per person per day. Total daily flow..------..-------------------..
------.gallons.
W Septic Tank—Liquid capacity..._....._..ga]lons Length................ Width_.....,..._.__.. Diameter_............._. llepth.._....___......
�+ Disposal Trenc6—No..---------.-----.. Width--------.--.---_ Total Length...._...--------- Total leaching area.-----------------sq. [t.
� Seepage Pit No.------_--.-_---_- Diameter-_----_---_._-_ Depth Uelow inlet-----.-----_---__ Totai leaching area------_--__--_sq. ft.
� Other Distribution box ( ) Dosing tank ( )
a Percolation Test Results Performed by------------------_.- __•-- ----. Date---.-------------__---__---•-------.
---------•---------��------•--------- P-- g
� Test Pit No. 1...._......._..mmutes per inch Depth of Test Pit__........._....... Depth to ground water...................__.
! L�,.- Test Pit No. 2.._......_.._nunutes per inch Depth of Test Pit.................... De th to round water......___....__..__...
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Description of Soil--------------------------------------------------------••----..---------._-------�----------------------�-
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(� Nature of Repairs o: Alterations—Answer when applicable..�__ S �� �
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Agreement:
The undersigned agrees to install the aforedescribed Individual $ewage Disposal System in accordance with
the provis:ons of.i::.:; S oi the'State Sanitary Code—The undersigned furtt:er agrees not to place the system in
operation until a Certificate of Compliance has been issned by the board of health.
Signed- --------------------------•-----�------•------------
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Application Approved By._�______ Dac=
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APPlication Disapproved for the foldouri /¢W'Of15 """"""'__""""""_"""'_"""""""""..."""""""""""""'"""_ Date
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Daze
Permit No.------------•--------•---_.
--------•---- Issued.--•_-----------------------------•----...---.___..
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� THE COMMONWEALTH OF MASSACHUSETTS
BOARD OF HEALTH
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I farz�ifux#e nf faum�littntr
THI� T ERT Y, That the Individual Sewage Disposal System constructed ( ) or Repaired (
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as been installed in acwr ance with the provisions of TI�'LE
application for Disposal \Vorks Construction Fermit Nu,_,__ S of �State Sanitary Code s scribed in the i
THE ISSUANCE OF THIS CERTIFICATE SHALL N�E O�ED SYeA Gt1ARANT E�NAT TME
SYSTEM WILL FUNCTION SATISPACTORY. I
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