HomeMy WebLinkAboutApp-Permit-Compliance ��
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THE COMMONWEALTH OF MASSACHUSETTS
BOARD OF HEALTH
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,���lirtt�Uan �ur �i���r�tt1 �.uxk� C�u���x-�tr#i�n �Cr�uti�
Application is hereby made for a Permit to Construct (� or Repair ( } an Individual Sewage Disposal
System at:
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C Location-Address or Lot No. .�
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Owtter Address
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Installer Address
Type of Building Size Lot.._..��.��_._...Sq. feet
� Dwelling—No. of Bedrooms.._.........��...............................Expansion Attic ( ) Garbage Grinder ( )
`� Other—T e of Buildin No. of ersons............................ Showers — Cafeteria.
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Q' Other fixtures --------------------------------------- ----
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W Design Flow..---...-•...-�.�.,�---------•----•-------gallons per person per day. Total dail flow-------------�-�...Z-4?-------•---------gallons.
t� Septic Tank—Liquid capacityl�_44?gallons Leng�th____�_'___ Width..___�`__.. Diameter_______________ De th_.__._�_�..
W Disposal Trench—No.____.�.......___. Width____.!�'.._._�_._`�`Total Length_._......_��'__��. Total leaching area,.���.___-s�-ft�f"�
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� Seepage Pit No........::........... Diameter.___..._._.____..._. Depth below inlet.....__.._.......... Total leaching area._...._...........sq. ft.
z - Other Distribution box (p�j Dosing tank O (
a � Percolation Test Results Performed by______�o_�?__.�.....1ot.1�.L�-E.f'_z-'.____..1..�� Date....�.�"��..'��_.. �
,� Test Pit No. 1_____C�_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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� Description of Soil_.__......��..� � ..f.�._T.__?.!__`tG.�"1.'�!T�_...._f.��:$�
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VNature of Repairs or Alterations—Answer when applica,ble______________...______.....____._..______._..___._._______....____.....__.._...._._._......._..
Agreement:
The undersigned agrees to insta.11 the aforedescribed Individual Sewage Disposal System in accordance with
the provisions of iITI,E 5 of the State Sanitary Code—The undersigned further agrees not to place the system in
operation until a Certihca.te of Complia;nce ha issue y the `Phealth.
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Application Approved BY- - ----�--- --------------•� ----------- l�--�
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•----------------------------------•------------._.._..._...._..----------Date
Application Disa.pproved f or the f ollowing reasons_____________� .___...._____
---•-•..............•---••-----------------•-•--•--.....----------------------••-------^^•---------•---.._.._.__...----•------------------------------------------------------••--Date--------------
� Permit No.---s�i.�..'��....�-----------------------_.__ Issue�._._._.�z.�..-//�.,.5�...----------...--•--------
i Date
THE COMMONWEALTH OF MASSACHUSETTS
BOARD OF HEALTH
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f�r�#ifutt� ,af f��aut�rlt�tnrr
THIS IS TO CERTIFY, That the Individual Sewage Disposal S;�stem constructed ( � Repaired ( )
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Installer
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has been installed in accordance with the provisions of TITLE 5 of The State Sanitary Code as described in the �
application for Disposal Works Construction Permit No.._____s��_1��__.__._.... dated._._.__�rr��,.ly__... . _ - • (
THE ISSUANCE OF THIS CERTIFiC�TE SHALL NOT BE CONSTRUED AS A GVARANTEE THAT THE �
SYSTERA WILL FUNCTION SATISFACTORY. �
'�i DATE----•--•------------------------------------------------------------------------ Inspector.-----•-------------------...__.._...----------•--------•--------._........---------
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