HomeMy WebLinkAboutApp-Permit-ComplianceTHE COMMONWEALTH OF MASSACHUSETTS
�-�--^ BOARD OF HEALTH
V..OF..... v.! .............................................
Appliratinn for Dispoiitt1 Works Towitrnrtion Permit
Application is hereby made for a Permit to Construct ( ) or Repair O an Individual Sewage Disposal
System at • oZ�- JaS 104A �J
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Location ocation - Address or Lot No.
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nor ' i d e
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a Installer Address
Type of BuildingSize Lot ............................ Sq. feet
Dwelling —No. of Bedrooms............................................ Expansion Attic ( ) Garbage Grinder ( )
Other — TYPe of Building ............................ No. of persons............................ Showers Cafeteria ( )
Q+ Other fixtures ......--•---•••-• ................ .
WDesign Flow......... ._........gallons per Person per day. Total daily flow .............. .................. gallons.
WSeptic Tank — Liquid capacity ............ gallons Length ................ Width ..... 7......... Diameter ................ Depthh-----------_-.----
x Disposal Trench — No...... j ............. Width ..... 3.......... Total Length............ Total leaching area..... T --sq. ft.
3 Seepage Pit No ..................... Diameter.................... Depth below inlet .................... Total leaching area .................. sq. ft.
Z Other Distribution box ( ) Dosing tank ( )
Percolation Test Results Performed by .......................................................................... Date ........................................
''la Depth of Test Pit..:.__....._.._..... Depth to ground water_._.____....:......__...
Test Pit No. 1................minutes per inch
Test Pit No. 2................minutes per inch Depth of Test Pit .................... Depth to ground water ........................
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oDescription of Soil ........................................................................................................................................................................
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U Nature of Repairs or Alterations — Answer when aplicable...� !�S' -4.
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Agreement:
The undersigned agrees to install the afor escribed Individu S wage Pisposal System in accordance with
the provisions of TITLE .5 of the State Sanitar ode — The and ed furt r agrees not to place the system in
operation until a Certificate of Compliance has 'ssued y th o h
Si.............................................. .........���.1 .._....
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Application Approved By__..._.._ .. ......... --- -.---
Date
Application Disapproved for the foil ' reasons: .......................................................................................................... . . .
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ate
Permit No.. ----------- _......._ Issued.._:..'OK _ . �........._D ......
.Date
/ THE COMMONWEALTH, OF MASSACHUSETTS
BOARD OF HEALTH
(Urtifuttte of. Tim'Pliot.rr
THIS IS -TO CERTIFY, That the Individual Sewage"Disposal System constructed ( ) or Repaired( _/()
by..... f_.c `_>....-- ......................................-----.......-•-------•----................---........
_Install ( /
at. ' G✓..... -x '1.... 1' ZG e �' ... =------....�� i. 3 .. -..........................` ..............................•--------------
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 .... dl�-_ =_._ 3 .. .......... 'dated.... :._:2. t f -----------------
THE ISSUANCE OF THIS CERTIFICATE SHALL NOT'BE CONSTRUED ASA GUARANTEE THAT THE
SYSTEM WILL FUNCTION SATISFACTORY. i
DATE. % Inspector..tii���'