HomeMy WebLinkAboutApp-Permit-ComplianceN
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THE COMMONWEALTH OF MASSACHUSETTS
BOAR OF HE H
oF...::...............:.. •.... .
,� rlu�tiion for 11ioi i Works Tonsiruriion "[amii
Application is hereby made for a Permit to Construct or
syst..._... ..... ... ...... .... _.... 0......
- Locatio • ddr�ess
Owner
i'
.... �-/_'n..............................................
Installer
Type of Building
Repair ( ) an Individual Sewage Disposal
A4 10 -LI
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or Lot No.
................................................. Ad ................................................
.... ............•--
Cless
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Address /
Size Lot. -2Q .� _....._.._Sq. feet
Dwelling — No. of Bedrooms.�.}.�..�.................................. Expansion Attic ( ) Garbage Grinder
Other —Type of Building -_W_ .....::........... No. of persons ............................ Showers ( ) — Cafeteria ( )
Other fixtures
c..................................................................................................................................................
Design Flow ............... .�$......_..gallons per perso Per day. Total it flow.......... = gal
lons.
Leng—KY..... Width.�____ Diameter________________ Depth.___:._..Se tic Tank — Liquid ca acity��.._ allons
Disposal Trench — No ...
�.. iameter-------/!...... Depth )below inlet ..... d:A..... Total leaching area. _.,.sq. ft.
Other Distribution box `) Dosing tank / Percolation Test Results Performed by.._V.r..... P)Ae'............................................ Date... Ila._......_..
Test Pit No. 1................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 ........................
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.% 1. . (---1-•------- --- -�z--------
Description of Soil...
Nature of Repairs or Alterations — Answer when applicable...............................................................................................
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Agreement:
The undersigned agrees to install the aforedescribed Individual Sewage Disposal System in accordance with
the provisions of TITIZ' 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 ued by the bDard of health.
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Application Approved By•-��.�:�:':�.:..---r --r ---------------•-----•--._..._....-----....------ - ----
ate'
Application Disapproved for the following mons-................................................................................................................
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,�@Date
Permit No..)(-. a.f I -----------------------------
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...........
.......
THE COMMONWEALTH OF MASSACHUSETTS
BOARD OF HEALT
l... a ........................... off....�Z?.Z.. .....................................
Trriifirair of
Tontpliam
IS ISTO CERTIFY, That the Individual Sewage Disposal System constructed (._)-or-Repaired ( )
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--- 11-.
F.'/ %�.., i Insta er
has been installed in accordance, with the provisions of TITLE hof The State Sanitary Cele s described in the
application for Disposal Works Construction Permit No._ r!f _ _4-------------------- dated__1�p�fi,��._..-----.._...---------.----
THE ISSUANCE OF THIS CERTIFICATE SHALL NOT BE CONSTRUED A A GUARANTEE THAT THE
SYSTI�liWIL .. U CTION SATISFACTORY.
DAT-----....� ` - Inspector.----- ---{ • ------ -----....................