HomeMy WebLinkAboutApp-Permit-ComplianceNo. -V__ k Si Fims......
THE COMMONWEALTH OF MASSACHUSETTS
�-� BOARD OF HEALTH
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Appliratiun for Disposal Works Tonsirurtion 11eruti#
Application is hereby made for a Permit to Construct ( ) or Repair O an Individual Sewage Disposal
System at:
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�% Location - Address or Lot No.
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/� Owner Address
Cl-' . ... ........................ ..................................................................................................
Installer Address
Type of Building//JJ Size Lot -.%l —0 0Z ---....Sq. feet
Dwelling —No. of Bedrooms .............. 1__ ------------------------- Expansion Attic ( ) Garbage Grinder ( )
Other — Type of Building ............................ No. of persons ............................ Showers ( ) — Cafeteria ( )
Otherfixtures------------------------------------------------------•-------------------------.---------------------------------------------------------------------
Design Flow ........ �Vy...........................gallons per person per day. Total daily flow -------------------------------------------- gallons.
Septic Tank — Liquid' capacity%QQ�._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..------..........------. r7
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 -----------------------------------------------------------------------•---.----------------
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Nature of Repairs or Alterations -Answer when applicable... <c t rs?� c �a T o sv Q o✓ ..............
!�tlt_` .._.. sP7'd .
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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_i steed by,he boardealth.
Application Approved
Application Disapprove
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/ �1 e� ate
Permit No-40Y.-rl C7�7........................... ------ Issued. :1:I� f.. ~----------
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��ryry f THE COMMONWEALTH OF MASSACHUSETTS
F_D
BOARD OF :HEALTH
tow!v ......................... OF ... y/g1e/t!lagx#.................................................
Trxrtifutt#e of Toutplinurr
CERTIFY, That the Individual Sewage Disposal System constructed
has been installed in accordance with the provisions of TITLEf The State Sani1
application for Disposal Works Construction Permit NAX._. a`f f ................... dat
THE ISSUANCE OF THIS CERTIFICATE SHALL NOT BE CONSTRUED AS
SYSTEM WIJLL FUNCTION SATISFACTORY.
Repaired ()<