HomeMy WebLinkAboutApp-Permit-Complianceed
No ................ .....
. Fps...........
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THE COMMONWEALTH OF MASSACHUSETTS
BOARD OF HEALTH
v;.
.........................----......OF....................................---------------------......._.......................
Appliratiou for Roposal Works C>z ustrurtiun Permit
Application is hereby made forma Permit to Construct ( ) or Repair ( ) an Individual Sewage Disposal
= ,system at, � . _
^ Loca ion - Address �� or Lot No.
OwnerAd ,� L J
s�. ti .__ s :141
!'-.'------------------------------------- ---- 4�...5.i S.l L 1.Ci. Ef Y /.. �%!�..: - - ...
Installer Address
Type of Building Size Lot.i,2#0.0_0--------- Sq. feet
Dwelling —, No. of Bedrooms.-Z-.7_..f......................Expansion Attic ( ) Garbage Grinder ( )
Other — Type of Building ............................ No. of persons .... _i'...................... Showers ( ) — Cafeteria ( )
Otherfixtures --------------------------------------------------------------------------------------------------------------------------------•---------------------
Design Flow .......... ._ _a....................gallons per person per da'y. Total daily flow.___.:9,50...._..................._...,dons.
Septic Tank — Liquid' capacity.il. .gallons Length .... 29/.6-_ Width.._ -.___6 . Diameter ................ Depth:.............
Disposal Trench — No ..................... Width ----- Y.......... Total Length.... ------------ Total leaching area. d,S_2: sq. ft.
Seepage Pit No ..................... Diameter .................... Depth below inlet .................... Total leaching area .................. sq. ft.
Other Distribution box t�/') Dosing tank ( )
Percolation Test Results Performed --------------
Y Date y7
Test Pit No. 1.....Y ........ minutes per inch Depth of Test Pit... 6........_.. Depth to ground water..__.S'! .............
Test Pit No. 2 ----------------minutes per inch Depth of Test Pit .................... Depth to ground water .........................
Description of Soil ...............................................................
...................................................................... ------------------------------------------------------------------------------------------------------------------------------•--
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 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 issued by the board of health.
Application Approved By ,`.. t
Application Disapproved for the following
�.....
Date
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�-t �� Date
PermitNo.---._S.�_.6------------------------------------------- Issued.---------�--------•--- V6 ......................
Date
THE COMMONWEALTH OF MASSACHUSETTS
BOARD OF HEALTH
.......................................... OF .....................................................................................
Tntifiratr of Toutpliatta
THIS IS TO CERTIFY, That the Individual Sewage Disposal System constructed ( ) or Repaired ( )
bY----------------------------------------------------------•----------------------------------- -----------------------------------------------------------------------------------------------
Installer
at......................................................................................................................................................................................................
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 ......................................... dated --------------------------------- _..............
THE ISSUANCE OF THIS CERTIFICATE SHALL NOT BE CONSTRUE® AS A GUARANTEE THAT THE
SYSTEM WILL FUNCTION SATISFACTORY.
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