HomeMy WebLinkAboutApp-Permit-ComplianceTHE COMMONWEALTH OF MASSACHUSETTS
BOARD OF H ALTH
TO (.J...........oF...... \`Gi �.r'�c�_ . .
Applutttion for Disposal Murky Tonutrnr#inn Errant
Application is hereby made for a Permit to Construct
System at:
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--',• • -- ation --Address
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caner
Installer
Type of Building
or Repair (V) an Individual Sewage Disposal
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or ot LNo.
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Address
Address
Size Lot So feet
Dwelling — No. of Bedrooms.......................................Expansion Attic ( ) Garbage Grinder ( )
Other — Type of Building ............................ No. of persons ......................... Showers ( t ) — 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 ........................
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Description of Soil.... ___
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Natua of Repairs or Alt ations — l nswer when applicable-__-_____� _�_._. _.n� ___.__fi_� ____ __________________
Agreement:
The undersigned agrees to install the aforedescribed Individual Sewage Disposal System in accordance with
the provisions of iITA i� 5 of the State Sanitary ode — The undersigned further agrees not to place the system in
operation until a Certificate of Compliance has a sued,py the board o iealth.
t�
gned_ - --= ............... CY-----------------------------------------------
Application
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Application Approved By..... _ ...... �� 1
Date
Application Disapproved for the f lowing reasons_______________________________________________________________________________________________________•------•--
•--•-----••--•---•-----------•••--••--------•- �------------•••-•----•---------•....................•------•--•-------.............................. ---•-----------
Issued
Date
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Issued -----•------•-•-.t D -.Permit No. = .3.y.. --- -
------------
Date
THE COMMONWEALTH OF MASSACHUSETTS
BOARD OF HEALTH
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Trrtifiratr of Toutpliaurr
THIS T CERTIFY, That the Individual Sewage Disposal System constructed ( ) or Repaired ()Qb n E-.9...
Installer
at �r, (........ ..tJI1-..t1F . ,1'ti,�1�7N
has been installed in accordance with the provisions of Tr.'n� r The State Sanita . wtl as �jeper' a ,1n the
application for Disposal Works Construction Permit No --------- dated--�{?Z-/__2i
1 THE ISSUANCE OF THIS CERTIFICATE SHALL NOT BE CONSTRUED AS A. -G A TEE THAT THE
y SYSTEWWFUNCTION SATISFACTORY. c
1
DATE_.).1. 19 � Inspector.-_-
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