HomeMy WebLinkAboutApp-Permit-ComplianceNo.. .._". ,C�,� Fim............... �...............
THE COMMONWEALTH OF MASSACHUSETTS
BOARD OF
I HEALTH
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...._._.......................
Applira#ion for Uispaoal Works Tonstrurtion pamit
Application is hereby made for a Permit to Construct (X) or Repair ( ) an Individual Sewage Disposal J
Sy tem :
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dam"
-L -cation -Address or
ner Address
--------------------------- ----------•-
Install -- - -••
er Address
Type of Building Size Lot ---------------------------- Sq. feet
Dwelling — No. of Bedrooms .......... ______________________________Expansion Attic ( ) Garbage Grinder ( )
Other — Type of Building .-.------------------------- No. of persons ............................ Showers ( ) — Cafeteria ( )
Otherfixtures----------------------------------------------•-------......--•---•---- --••-----------•-----•---•-------------.....-•--------•----------•--......----
Design Flow ............................................ gallons per person per day. Total daily flow ............I �:� ................... gallons.
Septic Tank — Liquid capacity.)PPP..gallons Length_ .............. Width ................ Diameter ................ Depth ................
Disposal Trench —No. ... L ......... Width .....Z............. Total Length .... 12 . . ........ Total leaching area ...!P -------sq. ft.
Seepage Pit No ..................... Diameter ... _................ Depth below inlet .................... Total leaching area .................. sq. ft.
Other Distribution box (>C) Dosing tank ( )
Percolation Test Results Performed by .................................................. ........................ Date ........................... --........__.
Test Pit No.4__ —�....minutes per inch Depth of Test Pit ..... 1�i-------- Depth to ground water .... ..............
Test Pit Nol... :!5z ... minutes per inch Depth of Test Pit ----- !Z ......... Depth to ground water..�4 ?jn.''_.._
Description of Soil... Tw!� �e - oI S-`= �r% a vj _v►'!!GAl.4?M. n d
'_`_ 5�e c Tt h s+�
I .....—.................................................................
Nature of Repairs or Alterations — Answer when applicable ...............................................................................................
•-------------•---------------........-•---------------------..._................--••-----•-----•-----.........----------------------------.....-------•-------------...---------------------.....•.....
Agreement:
The undersigned agrees to install the aforedescribed Individual Sewage Disposal System in accordance with
therovisions of TIT i .;:;.
p 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.
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D to
Application Approved By...................... ................................... 1..... .
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Date
Application Disapproved for the following reasons-----------------------------------------------------------------------------------------------------------------
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Date
PermitNo --------------------------------------------------------- Issued _.......................................................
Date
THE COMMONWEALTH OF MASSACHUSETTS
BOARD OF HEALTH
.................................. I....... OF ................................................. I ...................................
Tatifiratr of Tomplianrr
THIS IS, TO CE rRTIFY, hat the Individual Sewage Disposal System constructed (.k') or Repaired ( )
by -''a.,l:......t_.!'/� r <:�. 7 ------------------------------.. ---------------, -) - -•---.....-------------------......------------------------------
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==.�...------.. u z �:r. * = �: _ ----°------------=-----------------
has been installed in accordance with the provisions of TITLE j of The. State Sanitary C ,d as d cribed in the
application for Disposal Works Construction Permit No. _ _'_____r�_..��-_-- dated___ .'. ...... .. .............
THE ISSUANCE OF THIS CERTIFICATE SHA iI NOT BE CONSTRUED AS A G ARA TEE THAT THE
SYSTEMA WILL FUNCTION SATISFACTORY.
DATE.............•--.........-----•--•---•-•--------................-----------•---• Inspector.