HomeMy WebLinkAboutApp-Permit-ComplianceTHE COMMONWEALTH OF MASSACHUSETTS
''E3OARD OFt HEAL I F1
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Appliration for Disposal Works Tonstrtrrtion Prrutit
Application is hereby made for a Permit to Construct (K) or Repair ( ) an Individual Sewage Disposal
stem at:�:) pn-s, -tzz.> H ILL Rb. YNZPOU-M�R�T L�CTP44 U W +T A
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Address
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Installer Address �2
Type of Building Size Lot._____..?_____________----- Sq. feet—
Dwelling —No. of Bedrooms ............................................ Expansion Attic (P. -I Garbage Grinder ()
Other — Type of Building ............................ No. of persons ............................ Showers ( ) — Cafeteria ( )
Otherfixtures------------------------•-----------------------------.......---••-•-----.
Design Flow .._.._._._._eS-'_.. ......................gallons per person per day. Total dail flow_____1
Septic Tank — Liquid capacityl gallons Length.1��_ Width.4'.01. Diameter__-- - ------ Depth -;S -'B".
Disposal Trench — No ..................... Width .................... Total Length .................... Total leaching area -------------------- sq. ft.
Seepage Pit No____________________ Diameter....: ------- Depth below inlet.__ :tel-__- Total leaching area__1'i-__ ...... sq. ft.
Other Distribution box (X Dosing tank ( )
Percolation Test Results
Performed by._-.'`5T�Pj+.._ A -._t..__.___.__. Date____"
.................................
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Test Pit No. 1................minutes per inch Depth of Test Pit..... (_______....... Depth to ground water ____.__.
Test Pit No. 2 ............. ...minutesper inch Depth of Test Pit .................... Depth to ground water ....... -----
Description
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Description of Soil....................moo
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.......................... ..........
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Nature of Repairs or Alterations —
- Answer when applicable-------------------------------------------------------------
Agreement
The undersigned agrees to install the aforedescribed Individual Sewage Disposal System in
the provisions of TITLis 5 of the State Sanitary Code — The undersigned further agrees not to pl;
operation until a Certificate of Compliance has been iissVed ,}, i he board of health.,_,
Application Approved By..
Application Disapproved for the following reasons: ............................
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Permit No.__f/1/_--- - L l -------------------------- Issued------- -- ----- ------ (P G
Date
THE COMMONWEALTH OF MASSACHUSETTS
BOARD F HEALTH
................... 0 F....... .........................................
Tntifira tr of Toutpliattrr
in 40 ds�
THIS IS TO CERTIFY, That the Individual Sewage Disposal System constructed ( or Repaired ( )
by ------ 41112-".1t'`_f_. ............ '. J.Z.. %-•------ :-- ---------------------------------------------
----- --- -----------------� J;__ -------------------------------- _______ _---•---•____
nstaller
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has been installed in accordance with the provisions of TITLE 5 o. ,c The State Sanitary Code as deibed in the
a.__ _. _
application for Disposal Works Construction Permit No .. �_ f- _ _____________ dated ---- u_------ . ....................
THE ISSUANCE OF THIS CERTIFICATE SHALL NOT BE CONSTRUE® A U EE THAT THE
SYSTE UN IO SATISFACTORY.
....................
oDAT •- ---------•----•------ .............. Inspectr'