HomeMy WebLinkAboutApp-Permit-ComplianceNo-.V....��.....
THE COMMONWEALTH OF MASSACHUSETTS
BOARQ OF' HEALTH
......
.............1jl).......... OF........�. ----------------------------------------
Appliratiou for Disposal Warks T. ustrurtiou rrmit
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Application is hereby made for a Permit to Construct �6 or Repair ( ) an Individual Sewage Disposal
System at:
_...
.......... -:�:........, .-o. r ._�. �. .............. ................. Z 7 .....� .....--- .-------------•--- ....._..........
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Location - Address or Lot No.
...................... _........................................................................... •-•..........---------------•--••••................._......------•................................
ner //�� Address
6�_.ee i... � �G.........................••....... ............. --------------..............
Installer Address
Type of Building�Size Lot ............................ Sq. feet
Dwelling -No. of Bedrooms .............. j ........................ Expansion Attic ( ) Garbage Grinder ( )
Other — Type of Building ............................ No. of persons ............................ Showers ( ) — Cafeteria ( )
Otherfixt res -------•----------------------------------------•-----•-------------------------------------------._........---------------.......................----
Design Flow .............. ---------------.-gallons per person per day. Total daily flow .........__..___._.__.._...._..._.........._gallons.
Septic Tank —Liquid capacity,,rQQ.4fkallons Length ................ Width ........ --...... Diameter................ Depth ................
Disposal Trench — No ..................... Width .................... Total Length .................... Total leaching area _................... sq. ft.
Seepage Pit No ..................... Diameter ............. ....... Depth below inlet.................... Total leaching area .................. sq. ft.
Other Distribution box ( ) Dosing tank ( )
Percolation Test Results Performed by .......................................................................... Date ........................................
Test Pit No. 1................minutes per inch Depth of Test Pit .................... Depth to ground water ........................
Test Pit No. 2................minutes per inch Depth of Test Pit .................... Depth to ground water........................
Descriptionof Soil ----------------------------------------------------------------------------------
...................................................... ............ -.................................................................................................................................
Nature of Repairs or Alterations — Answer when applicable............................................................................................
Agreement:
The undersigned agrees to install the aforedescribed Individual Sewage Disposal System in accordance with
the provisions of TITLE 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 by the board of health.
Application Approved
................................
Date
Date
Application Disapproved for the following reasons-----------------------------•-----------------------------------------------•------------------------.._...-.._
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Date
PermitNo ......................................................... Issued .......................................................
Date
THE COMMONWEALTH OF MASSACHUSETTS
BOARD OF HEALTH
.�......... .. 0 F......... 1" d .l.... .............................
Trrtffira4 of Tout rliattrr
THIS IS_TO CERTIFY, That the Individual Sewage Disposal System constructed ( or Repaired ( )
by
at........--- _40.Z --, y.. •---... '.f :.:7 ....... � --------------------------------------------------------------------------------------------------
has been installed in accordance with the provisions of TIT F 5 of The State Sanitary Code as described in the
application for Disposal Works Construction Permit No... _". _ ....... dated.- °v''
THE ISSUANCE OF THIS CERTIFICATE SHALL OT BE CONSTRUE® AS A GUARANTEE 20T THE
SYSTEM WILL FUNCTION SATISFACTORY.
DATE...................•-•-.........------------------....-----•-------•-----------• Inspector