HomeMy WebLinkAboutApp-Permit-Compliance'?r THE COMMONWEALTH OF MASSACHUSETTS
BOARD OF HELTH
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Applirttiion for Disposal Works Cion-strur#ion lirrutit
Application is hereby made for a Permit to Construct (A or Repair ( ) an Individual Sewage Disposal
System at:
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Location - Address or Lot N
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Owner Address
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a 3. ---•--.. "if ----------------------------------- ----------- ----------------------_....------.-----....---...._.............. -....... Installer Address �--
Type of Building Size Lot _..��1�.�..............
U! ....Sq. feet
Dwelling —No. of Bedrooms............................................Expansion Attic ( ) Garbage Grinder ( )
P., Other — Type of Building ____________________________ No. of persons ..... `.�".................. Showers ( ) — Cafeteria ( )
Otherfixtures----.._..-•--•---•--------•--------•.........................-•----.....__..........------•------•--•-----••------....-----•----•-----........•--•-_..
W Design Flow ............. Sr........................gallons per person per day. Total daily flow ........ ��___'-�____2 ....................... gallons.
WSeptic Tank— Liquid' ca.pacity.1M. ..gallons Length._$s_1�... Width_4.g.?�_..._ Diameter________________ Depth._4 c_O.. .
x Disposal Trench — No. ..... I ............. Width .... 3�n .......... Total Length_.. Z o......_.. Total leaching area ... 1.(P Q........sq. ft.
Seepage Pit No ..................... Diameter .................... Depth below inlet.................... Total leaching area .................. sq. ft.
z Other Distribution box ( ) Dosing tpttk ( )
a Percolation Test Results Performed......... Date... ��g ��y .
Test Pit No. 1.... i':_. ...... minutes per inch Depth of Test Pit ._ L :t ........... Depth to ground water... P9:9!v S.._..
W Test Pit No. 2 ---------------- minutes per inch Depth of Test Pit .................... Depth to ground water ........................
P4......-•-•-••-•--•--••••......--•..............................••_... _--•---....---..................... ,..................................
Description of Sc
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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 MITIE' 5 of the State Sanitary Code — The undersigned further agrees not to place the system in
operation until a Certificate of Compliance hasb en�y the board of health. V Signed.. G� ...Application Approved By..--- 'J
Date
Application Disapproved for the following reasons:-•-•.............•-•-------.............---•----------...........-------------•----.....•-••--........•----_...
PermitNo... ...............................................
Date
Issued............. ,-...... •--•--- ....
Date
THE COMMONWEALTH OF MASSACHUSETTS
BOARD OF" HEALTH
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(Inr#ifirab of Toutplinna
THIS IS TO CERTIFY, That the Individual Sewage Disposal System constructed (----y or Repaired ( )
by....-••-•----•-•--......----•----......--••-------------•-------- . •----...---•----.......-----•-•---•---------------.....---....•••-•-----•--•-•----•---••-------
�j�staller
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at.......... .r �CY ..,._ J 4- J 7 %... } :--------------•--•--.....__.................._.._._.........._......__.._........-----.....
has been installed in accordance with the provisions of TIME 5 of The State Sanitary Code as described in the
application for Disposal Works Construction Permit No..J.. Axl . ................ dated ..........
%�':_:c�_Y_..........._.__.....
THE ISSUANCE OF THIS, CERTIFICATE SHALL NOT BE CONSTRUED AS A GUARANTEE THAT THE
SYSTEM, WILL FUNCTION- SATISFACTORY.
DATE. ..: ......................................................... Inspector L_, ......... ........................................................