HomeMy WebLinkAboutApp-Permit-Compliance. _
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r*EcowMowWEAcreoFwAoSxonuscrrs
BOARD OF HEALTH
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Aplifirativit for B at i0orkii Tiatuitrurtion Vrrutit
Application is hereby made for a Permi to Construct or Repair an Individual Sewage Disposal
- -------------- -- -- . ... . .. .. ... .. ........... . --- e5r.-I --- -5 ---- --- ----- --- -- 7--/ .........
ocation - A, dress or Lot No.
Owner Address f
Address
'
Dwelling No. of oourvvouu---'�-------_------_-^`�ppq�mv� Attic "^^"°u= .=^i""=
Otherr--Iypc of Bnii6iu& -------------- No. of persons ---------------------------- Showers ( ) -- Cafeteria ( )
()tbcr fixtures --_----.-----------------_----------_--__-.-------------'------------_
Design Flow ............ gallons per person per day. Total daily flow .................. -....................... gallons.
Septic Tank—Liquid capacity. ------ gxDooy Lcne6z-------- Width --------' Diameter ---------------- Depth ................
Disposal Trench --No. .................... Width ---'TotalLength ...... ............. Total leuchingurea-----_--'-og ft.
> �c�Do�c �� �o----��-_-' Diameter-��-'/�--' Depth below inlc�----_----Iota area -_-'---...sq. �.
Other Distribution box ( ) Dosing tank ( )
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Percolation Test Results Performed by -------------------------------------------------------- ................. Date --------_--_-------.-
Test Pit No. l ---------------- minotcuper inch Z)cpr6 of Test Pit -------------------- Depth to ground water .----------.
4.4 Test Pit No. 2. ' --zu�o�esper inch Depth of Tex P�..--------' Depth to ground water ........................
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`� Description of --�-'-_----_----------_---'--------------_---'----.--_--'--_-------_-'
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U Nature of Repairs or Alterations — Answer when applicable -_---------_---_------_---------------'--------
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Agr,cozroc:
The undersigned agrees to install the aforedescribed Individual Sewage Disposal System in accordance with
the provisions of Article XI of the State Sanitary Code— The undersigned further agrees not to place the system in
operation notJ u Certificate of Compliance has been iaaoul bythe board of health.
gnede ---------------- -a ---- --------
Application Approved By ----- --
Date
Date
THE COMMONWEALTH opMASSACHUSETTS
BOARD OF HEALTH
4�s -1 � - I 'p'
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0 Installqr
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asAescri�ed in the
has been installed in accordance with the provisions of Articl X hie S�tate Sanitary C*
application for Disposal Works Construction Permit No ... ����JL_.-_-_--_- dateJ-'. ---------
THE
--'_THE ISSUANCE OF THIS CERTIFICATE SHALL NOT BE CONSTRUED AS A GUARANTEE THAT THE
SYSTEM WILL FUNCTION SATISFACTORY.
DATE.......... ............... ...................................... ---........ Inspector. -. 6---------_
THE COMMONWEALTH orMASSACHUSETTS
BO� H
lNo-�,��-- �� ^��'-'~-�~--------�- --� --''c�-----BEs
Permission
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asshown oothe application for Disposal Works Construction
FORM 1255 HOBBS & WARREN, INC.. PUBLISHERS