HomeMy WebLinkAboutApp-Permit-Compliance ;�:; � ,
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THE COMMONWEALTH OF MASSACHUSETTS
BO�eRD OF HEALTH
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Application is hereby made for a Permit to Construct (• or Repair O an Individual Sewage Disposal
System at•
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Location-Address r • �
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a Installer Address
� Type of Building Size Lot____________________________Sq. feet
� Dwelling—No. of Bedrooms...�_________________________________Expansion Attic ( ) Garbage Grinder ( )
p,,, Other—Type of Building ____________________________ No. of persons__...__._________.__.__.__._ Showers ( ) — Cafeteria ( )
a Other fixtures -----------------••--------------. ...---
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Design Flow_____________�.�_____.. .___._____._gallons per person per day. Total daily flow.._.._.___..��.'.�.'__...__._____gallons.
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Septic Tank—Liquid capacit�o.__gallons Length._$_'___._. Width___._�,___._ Diameter________________ Depth__�. ._ �
� Disposal Trench—No.._./_____________ Width__!�l�..�__._____ Total Length._.Z_.t_�_.... Total leaching area_�.,7.�.�.__�.
� Seepage Pit No..................... Diameter._._______._______._ Depth below inlet____.._.........____ Total leaching area_________._.__....sq. ft.
z Other Distribution box ( �,Y Dosing tank ( ) _/
'"'' Percolation Test Results Performed by..___1`�'�'.�'l3-,l...��L�-'�?:J--------••---• Date___�����►_.__..
aTest Pit No. 1................minutes per inch Depth of Test Pit._._____..._._.____. Depth to ground water_..___.._...___._.......
fi, Test Pit No. 2________________minutes per inch Depth of Test Pit.._______.________.. Depth to ground water.___._.___._____.__..._.
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VNature of Repairs or Alterations—Answer when applicable_______________________________________________________________________________________________
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Agreement:
The undersigned agrees to install the aforedescribed In, ' 'dual Sewage Disposal System in accordance with
the provisions of iIT� 5 of the State Sanitary Code— e u dersigned further agrees not to plac�the s stem in
operation until a Certifica,te of Compliance ha.s been is e y t oar of health. �
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igned_ 4_ --------------------------------------- �-�--a��__...::�.._
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ApplicationApproved By._... - -•--------- - ---- .. - - ------- .-- -.....------.....--------.......- ---------c-�--------------��----
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Applieation Disapproved f or the f ollowing reasons________ _____ _
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Permit No..----a..�---�-�-���----------------------- Issued.._..----�-• -�---�.��------•--••-------
Date
THE COMMONWEALTH OF MASSACHUSETTS
BOARD OF HEALTH
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f��er#ifutt#� �af (�uut��i�tnr�
_TI�S I T�O,�CERTIFY, That the Individual Sewage Dispo�l S�stem constructed ,(�✓S�or Repaired O
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has been installed in accordance with the provisions of TI F 5 of The State Sanitary Code as described in the
application for Disposal VVorks Construction Permit No.__��_""�---�-�----•--- dated_._._�".�_'_�-��_-_��.............
THE ISS�ANCE OP THIS CERTdFICATE 51�9ALL NOT BE CONSTRUED AS A GiJARANTEE THAT THE
SYSTEI�A WILL FUNCTION SATISFACTORY.
DATE------•--------------•-•-•--•-•----------.._....._..-•------•------------------• Inspector....-------...--------------•---------------•--------------...----------...-•------- '