HomeMy WebLinkAboutApp-Permit-ComplianceF ims ...........................
THE COMMONWEALTH OF MASSACHUSETTS
BOARD OF HEALTH
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Appliration
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for Disposal Workii Ton r7an
Application is hereby made for a Permit to Construct ( ) or Repair (ndividual Sewage Disposal
System at: 0
.J.; __ y Zd'T- )V / 16 MAP- I
/ _ or Lot No.
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Address
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Installer Address
Type of Building Size Lot ............................ Sq. feet
Dwelling — No. of Bedrooms............................................Expansion Attic ( ) Garbage Grinder ( )
Other — Type of Building ____________________________ No. of persons __...____- _._.___..____.___ Showers ( ) — Cafeteria ( )
Otherfixtures -------------------------------------------------------------------------------------------------------------------...--------------------------------
Design Flow --------------------------------------------gallons per person per day. Total daily flow -------------------------------------------- gallons.
Septic Tank —Liquid capacity ............ gallons Length ................ Width ................ Diameter ................ Depth ................
Disposal Trench — No_____________________ Width .................... Total Length .................... Total leaching area .................... sq. ft.
Seepage Pit No ..................... Diameter .................... Depth below inlet.................... Total leaching area .................. sq. ft.
Other Distribution box ( ) Dosing tank ( )
Percolation Test Results Performed by .......................................................................... Date ----------------------------------------
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........................
Descriptionof Soil ------------------------------------------------------------------------------------------------------------------------------------------------------------------------
..................... -••---•------------------••---------------------------•-----•-•-•------•--------------•--------•------•-----------------------------•------------------••--------...---------------
---------- ---- - &Q-fle4d Nature of Repairs or Alterations — Answer when applicable.________ ___,lL__�—rid ---- 111 -
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Agreement :
The undersigned agrees to install the aforedescribed Individual Sewage Disposal System in accordance with
the provisions of TITTIE 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 by the board of health.
,.Signed .......-•------••------------ ---------• ate .....
Application Approved By ....... ./ -- ._.... _ - (q------------------•-•--••••••• ___-.l___ _.__lz __..._
/�° � ,, � - •---.....----•----....... to
y� .' r'"` 1�'
ie l h .Off i cer
Application Disapproved for e f oll"owang reasons: ................................................................................................................
.............................................. ................... Da
PermitNo --------------------------------------------------------- Issued .................................
Date
THE COMMONWEALTH OF MASSACHUSETTS
BOARD OF HEALTH
//�fid
.............. l..U. ...... O F..... .............................................................._._.
Tntifirate of Tontpliatta
he Individual Sewage Disposal S- or Repaired
constructed )
THIS IS TO CE��r�',, That t stem g p �' (
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nstall-
` install -
at
at... ------;f �.. .......... ...............
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has been installed in accordance with the provisions of TIT F 5 f The State Sanitary C-94,as d cr' in the
application for Disposal Works Construction Permit No ..... "•7 .............. dated -- .1. 3_ ..' __.._._______......
THE ISSUANCE OF THIS CERTIFICATE SHALL NOT BE CONSTRUED AS A G ARA TEE THAT THE
SYSTEM WILL FUNCTION SATISFACTORY.
DATE................................................................................ Inspector.