HomeMy WebLinkAboutApp-Permit-ComplianceNo. ...":..,7 ............ . ............_
THE COMMONWEALTH OF MASSACHUSETTS
BOARD OF' HEALTH
.............. ..--•-------•--•--..OF......... ............................................
for Disposal Works Tonoirurtion "prrutit
Application is hereby made for a Permit to Construct (') or Repair an Individual Sewage Disposal
System at:
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to - AdAress or Loi No.
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O ner Address
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Installer Address
Type of Building Size Lot ............................ Sq. feet
U Dwelling —No. of Bedrooms ............ 5a ___________ _ _ _____Expansion Attic ( ) Garbage Grinder ( )
Other — T e of Building No. of persons ............................ Showers — Cafeteria
04
d Other fixtures .........---•-----•---••-••-•••--•--- ---------------------------------•------------------------------------...-----------------
W Design Flow -------------------------------------------- gallons per person per day. Total daily flow ............................................ gallons.
WSeptic Tank Liquid capacity ............ gallons Length ................ Width ................ Diameter ................ Depth ................
x Disposal Trench — No . .................... Width .................... Total Length .................... Total leaching area .................... sq. ft.
Seepage Pit No ..................... Diameter .................... Depth below inlet____________________ Total leaching area .................. sq. ft.
Z Other Distribution box ( ) Dosing tank ( )
Percolation Test Results Performed by.......................................................................... Date. .......................................
Test Pit No. I................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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0 Description of Soil ........................................................................................................................................................................
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U Nature of Repairs or Alterations — Answer when applicable___._ XIAZ- A! _._ ems:.. X67` .. �__... .T,k �
Agreement:
The undersigned agrees to install the aforedescribed Individual Sewage Disposal System in accordance with
the provisions of iITIE 5 of the State Sanitary Code — The undersigned further agrees not to place the system in
`r operation until a Certificate of Compliance has been issued by the board of health.
Signed.._. .---••----._.....•---_.----- .---------------•-------••-------•----•---•---•-.•-
�j Date
ApplicationApproved By--- •-- -• -• ---- • -------=--•--•---••---•---------•--•---•--•---•-•-----•------•- •-----_•4 •�� .. ...........
Application Disapproved f o e f ollo ng reaso :-•••---•-•-----•-----•--•---------------•-••-------•----•-•---•-•-----•••-•---....--------... --•-•--------•--•-
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Date
Permit No....---- -•----------------------- Issued_. Zx 1gq------
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THE COMMONWEALTH OF MASSACHUSETTS
BOARD OF HEALTH
..................OF..... al'`i`..............................................
Tnr#ifirttir of Toutplitturr �.
THIS'"IS TO CERTIFY, That the Individual Sewage Disposal System constructed ( ) or Repaired
by............. ,��.hd __t /Lo S= `''''r t`:.. ' ---------------------------------------------------------------------------------•---------...---._...-•-----------------
Installer
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has been installed in accordance with the provisions of TIT' 5 of The tate Sanitary Code as described in the
application for Disposal Works Construction Permit No.___._ _"----- dated _..._._.�__�_���...... _..
THE ISSUANCE OF THIS CERTIFICATE SHALL NOT BE CONSTRUED AS A GUARANTEE THAT THE
SYSTEM WILL FUNCTION SATISFACTORY.
DATE.--------�. .1 ------------------ Inspector- -
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