HomeMy WebLinkAboutApp-Permit-ComplianceTHE COMMONWEALTH OF MASSACHUSETTS
BOARD OF HEALTH
OF...........................................................
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Appliration for Disposal Works TonstrWiott JIrrnnit
Application is hereby made for a Permit to Construct ( ) or Repair an Individual Sewage Disposal
I
sy at ..._.......... ................•.. ............. ......... l .......
.....__...J..:. N_..� � l-l_Na/._n..Address ..................................... fx'!C7 sor ....................
U� ^Owner ) t , ddress
.... k....._.. -•.....................................................................................................------............................._.
Installer Address
Type of Building Size Lot ............................ Sq. feet
Dwelling —No. of Bedrooms..........................................Expansion Attic ( ) Garbage Grinder ( )
Other — Type of Building .......................... No. of ersons ............................ Showers ( ) — Cafeteria ( )
Otherfixtures ................•------.--....._.........................-•-------------•---..................-•-.........-------•-----".........................
Design Flow...........................................gallons r per n per day. Total daily flow .....__..._.__............_.................gallons.
Septic Tank — Liquid capacity ....... .... gallon ngth................ Width ................ Diameter ................ Depth ................
po ft.
Disposal Trench — No ................. Width ........._. _.. Total Length .................... Total leaching area ...................sq.
Seepage Pit No ..................... Dia eter ........ ........... epth below inlet.................... Total leaching area .................. sq. ft.
Other Distribution box ( ) D sing tank ( )
Percolation Test Results P rform bY.......................................................................... Date ........................................
Test Pit No. I................mi tes r inch Depth of Test Pit.................... Depth to ground water........................
Test Pit No. 2................minu er inch Depth of Test Pit .................... Depth to ground water........................
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Descriptionof Soil.................................................................•---------......-•---......---•--------....---------...----------..................---.._..-----•---...
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Nature of Repairs or Alterations —Answer when applicable___�'� ..__! !.._. e!....�Y....O�.........................
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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 issued bpk bo d of health. t�
ied . ---- �............... ...__.......----_-"............ /
may. -
A
Application Approved B ... ..:..--- . <,(
PP PP Y•-.......- -..... ----------------------•--- ...--
ate
Application Disapproved for the f ollouritq reasons:
Permit No...<? .1 ............... _........ _.._...... Issu .. f./_. .V.V ......_nau..._
Daee
THE COMMONWEALTH OF MASSACHUSETTS
BOARD OF HEALTH
.... O F'... L ..........................................:...............
Tprtif irate of Toutplianu r
THIS IS TO CE�R,P"r,FY, That t�i� Indidual Sewage Disposal System constructed ( ) or Repaired ( �
at ..........:�L ...... CA �.._�� cr /<... �21, Iglu /� `�
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has been installed in accordance with the provisions of TT�-�F rr The State Sanita Coded in the
application for Disposal Works Construction Permit No... ..................................... dated ...... A ... �... ��; ......--.....
THE ISSUANCE OF THIS CERTIFICATE SHALL NOT BE CONSTRUED AS EE THAT THE
SYST WILL FUNCTION SATISFACTORY.
DATE`S c� `V9 ��, l�
.... Inspecto
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