HomeMy WebLinkAboutApp-Permit-Compliance<r .
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THE COMMONWEALTH OF MASSACHUSETTS
BOARD OF ,HEALTH
- ............ ...................... OF .....
.
Appliration for Riip ual Works Tomitrur#ilau Frrutit
Application is hereby made for a Permit to Construct ( 4 }i r Repair ( ) an Individual Sewage Disposal
System at
--
Location - Address or Lot No.
Owner
Address _
Installer
Type of Building
Address
Size Lot__,/C..Sq. feet
Dwelling —No. of Bedrooms .______. . �7 ..____________________________Expansion Attic (
) Garbage Grinder ( )
Other — Type of Building ____________________________ No. of persons .......... _................. Showers ( ) — Cafeteria ( )
Otherfixtu=s ................. ----------------------------------- •...............
-•--------------- .............................................................
Design Flow ............. _i5 ---------------------- gallons per person er day. Total daily flow ....... _�_��___Ze_0..................... gallons.
Septic Tank—Liquid capacity/�^�allons Length___ ____-.____ W>dth_.'K��.___
Diameter________________ Depth___1"e_
Disposal Trench — No_ ____________________ Widt..................... Total Length ---------- r--------
Total leaching area .................... sq. ft.
Seepage Pit No ..... �/___________ D eter.__sd_ _._. Depth below inlet__ '_4. . ` Total leaching area__?&�q. ft.
Other Distribution box - Dosing
(Z tank
Percolation Test Results Performed
Date. .��?�r r:
______________ __t�'_C? ..._-.
Test Pit No. 1_-�_minutes per inch Depth of Test Pit__%�l y_. Depth to ground water _____:___.
Test Pit No. 2 ................ minutes per inch Depth of Test Pit .................... Depth to ground water ........................
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j----------------------
Description of Soil--- = +�
` `'�---•-----••---•--------''!'..- ..... 1 --------------
-------------------- -------_------- -------------------------------------------------------------------••-•---•---.--------------------------------------------------------•-•--------
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 TITLE
p 5 of the State Sanitary Code —The undersi urtl:er agrees not to place the system in
operation until a Certificate of Compliance has bee s e the b rd of ealth.
Signed:' _ _ s� - ,,
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�
ApplicationApproved BY ----••--------------------•-----•....-•------------------------------------•- •-•-• ------------
Date
Application Disapproved for the following reason :-----•--••---------•--•••••-•---- ---•---••--•--•---••----•--•••------------••-•-•----•-•--•••------------------
------------•----------•---•-••--•----• ......................................................... -.......................................................................................................
Date
PermitNo ......................................................... Issued --------------------------------------- ---------------
Date
THE COMMONWEALTH OF MASSACHUSETTS
BOARD OF HEALTH
......................................... OF .......:.... : ..............
Trriifiralle laf f�uut�rlittur�e
THIS IS TO CERTIFY, That the Individual Sewage Disposal System constructed ( { -`o"r Repaired ( )
by:: } f r. = -=. --------..r` ==3--- = �----- ----- - -----------------------------------------------------------------------------------------------
Installe
at..................................
has been installed in accordance with the provisions of TITLE: j of The State Sanitary Code as described in the
application for Disposal Works Construction Permit No... ...................................... dated .......................................... 00 ---
THE ISSUANCE OF THIS CERTIFICATE SHALL NOT"COTRUE®,A- - UARANTEE T0�1 � WE
SYSTEMA WILL F C O SATISFACTORY.
DATE ...... - ---
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