HomeMy WebLinkAboutApp-Permit-ComplianceYNo....a,.. � .� Fps ... ...... � Z/V
THE COMMONWEALTH OF MASSACHUSETTS
B R OF HEALTH
...................... I ........ OF.........................................................................................
Application is hereby made for a Permit to Construct (or Repair ( ) an Individual Sewage Disposal
System at:
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tion -Address or Lot No.
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Address
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Installer Address
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Type of Building SizeLot_ �.® 1 ---- Sq. feet
Dwelling—No. of Bedrooms ___...3 ---------------------------------Expansion Attic ( ) Garbage Grinder ( )
Other — Type of Building ............................. No. of persons ............................ Showers ( ) — Cafeteria ( )
Otherfixtures---------------------------------------------------------------------------------------------------- ...............................................
Design Flow ........... �r` _5........................gallons per person per day. Total daily flow ---- _............ �✓"..a—'"___ S'............galls.
Septic Tank — Liquid capacity,'�°c'O__gallons Length .... 55!....... Width ....._%_--___ Diameter_______________ Depth.-_%........
Disposal Trench — No ..................... Width .................... Total Length .................... Total leaching area .................... sq. ft.
Seepage Pit No.... / .............. Diameter.l0 •_ _'*'.__. Depth below inlet ... j C-;�_ct...... Total leaching area.. .... sq. ft.
Other Distribution box Dosing tank
Percolation Test Results Performed by --- 4je s -J_.__ _.__- _L G `- _ _.- '- �__-_ Date... _..!21 ... .�.Z.....__--
Test Pit No. 1.-�_Z--_minutes per Inch Depth of Test Pitl,Y�.____ 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__ T .......... —�r ....... -----------------------
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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 TIT l ,;::. 5 of the State Sanitary Code — The undersigned further agrees not to place the system in
operation until a Certificate of Compliance has been issued b �the board of health.
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Application Approved By ... VD'--Wngre
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--- D'te
Application Disapproved for the f ----------------------------------------------------------------------------------------------------------------
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p Date
Permit No.---- Z. .._..l-- ----------------------- Issued --------------� / L
Date
THE COMMONWEALTH OF MASSACHUSETTS
BOARD OF HEALTH
................................. I........ OF .....................................................................................
�rr�g��rtt� laf (�um�li�t�t��e
THIS IS TO CERTIFY, That the Individual Sewage Disposal System constructed ( ) or Repaired ( )
by------------------------------------------------------------------------------------------------------------------------------------
Installer
at------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------
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 ----------------------------------------- dated_ ......._._._._...___-_______---_-- .......
THE ISSUANCE OF THIS CERTIFICATE SHALL NO;C:OTR ®— GUARANTEE T THE
SYSTEM WILL FU CTION ATISFACTORY.
DATE-------------- ---- .�-----...--- Insp----------.