HomeMy WebLinkAboutApp-Permit-ComplianceNoFR.E ..............................
THE COMMONWEALTH OF MASSACHUSETTS
(4-5 -) I
SOTOBOARD OF HEr-,%a TH
IT— Il3q .................. OF ...... . .. . ......... .. . ......... ....................................
Apphration for Dip at Works Towitrurtion Permit
Application is hereby made for a Permit to Construct (k -y -or Repair an Individual Sewage Disposal
System /<
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ss
.atw Address atio Lot -No.
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Owner
wner Address
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Installer Address
Type of BuildinEr Size Lot____________________________ Sq. feet
Dwelling—
ooms ---- ................................. Expansion Attic Garbage Grinder
v1Vo. of Bedr
Other—Type of Building _. .......................... No. of persons____________________________ Showers Cafeteria
Other fixtures -----------------------------------
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Design Flow ............................................ gallons per person per day. Total daily flow -------------------------------------------- gallons.
Septic Tank—Liquid capacity -------- --- gallons Length________________ Width________________ Diameter_._.._.____...__ Depth__________ --_-.
x Disposal
epth---------_-----
Disposal Trench — No_ ____________________ Width .......... Total Length____________________ Total leaching area .................... sq. ft.
Seepage Pit No.__c.-_2 . . ..... ... Diameter__________,_.__ Depth below inlet____________________ Total leaching area. ----------------- sq. ft.
Z Other Distribution box ( ) Dosing tank ( )
Percolation Test Results Performed by ---------_--_--------- ------------------------------------------------ Date_ .....................................
Test Pit No. 1 ................ ininutes per inch Depth of Test Pit____________________ Depth to ground water_______________________-
J-:,
ater------------------_----
0:4 Test Pit No. 2____________ ___minutes per inch Depth of Test Pit____.________._.____ Depth to ground water___.______.___________._
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0 Description of Soil__;;_ --- ..................................................................................................... ................................
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Nature of Repairs or Alterations — Answer when applicable -------------------------------------------------------------------------------------- ---------
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Agreement:
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 until a Certificate of Compliance has been issued by the board of health.
igne. ....... ..... - ---- --------- ------------_-------- ------------------------_ --------------
legApplication Approved By— .. ..... ...... re—, - -------------------------------------------------- IK -- ----
Date
Application Disapproved for the following reasons: -------------------------------------------------------------- --------------------------------------- ---------
.............................. ............... ......... ------------------------------------------------------------------------------------------ -----------------------------------------------------
Date
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Date
PermitNo..//4..�.•----------------------•--------_. Issued ----------------------------------- ....................
Date
THE COMMONWEALTH OF MASSACHUSETTS
BOARD OF HEALTH
. . .........
. . . . . . . . . .
...........................
of utphaurr
T S 0 IF That the I u vgeDisposal System constructed mor Repaired
by.... ...... .... ............ -------------- ------------------_ ................................
;�---- ----- ... ...... -It ...... ------------------------------------------------------------------------
has been installed in accordance with the provisions of Artic X of The State Sanitary Co s decribed 1A `the
application for Disposal Works Construction Permit No. - - ------------------------ dated ---
THE ISSUANCE OF THIS CERTIFICATE SHALL NOT BE CONSTRUED AS A C&IJARANTEE THAT THE
SYSTEM WILL FUNCTION SATISFACTORY.
DATE. ................................................................................ Inspector__.___..�� -- ----------_-------
THE COMMONWEALTH OF MASSACHUSETTS
BOARD HEALTH
No.... ........ ... OF......_... . ......... ... .. ... ..... .......... A ........... ....... FEr± ........................
7n
Permisslap�is hereby granted--\. �__ ----- �1__i
to Co atj Individi
at Nn��N ------ •�'o =z
as shown on the application for Disposal Works
DATE----------------------------------------------------------------
FORM 1255 HOE38S & WARREN, INC., PUBLISHERS
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Ic it -//Health
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oard . Health
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