HomeMy WebLinkAboutApp-Permit-ComplianceTHE COMMONWEALTH OF MASSACHUSETTS
BOAR® OF HEALTH
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ApplirFation for Dis#o,ial Works Tonstrnrtion jhrmit
Application is hereby made for a Permit to Construct (I/) or Repair ( ) an Individual Sewage Disposal
tem
at:
IC
Location - Address or Lot No.
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W � caner
� Installer --------------------------•--
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Address
Address
Type of Building Size Lot__y._=__ 7.Sq. feet -Z
Dwelling—No. of Bedrooms .....................r7....................... Attic ( ) Garbage Grinder (A40
Other —Type of Building ____________________________ No. of persons____________________________ Showers ( ) — Cafeteria ( )
Otherfixtures ------------------------------------------------•-----.-••--------•--------------------•----•------•----------•--------------•--•--------•-•-----•----
Design Flow ................
S__gallons per person per day. Total daily flow __________________.__�.Z�_........ gal o s.
Septic Tank — Liquid capacity_ O60gallons Length__"__"_ — Diameter ------- _-...... Depth ....
Disposal Trench — No_ ____________________ Width .................... Total Length .........___________ Total leaching area ..................... sq. ft.
/y
Seepage Pit No ........ /.----------- Diameter_________!_____ Depth below inlet ...... _J`___........ Total leaching area____./ ___ _.6_.'.`9q. ft.
Other Distribution box (,/,9�; Dosing tank ( )
Percolation Test Result Performed by ........ '.__ s ____ '4Z .................. Date_ _O__. 3pt___ �Ycy_ 3
Test Pit No. 1 ----- _—__`Z_minutesper inch Depth of Test Pit --- 1`?�y_'_' Depth to ground water ......... ..... __-
Test Pit No. 2 ................ minutes per inch Depth of Test Pit .................... Depth to ground water ........................
............... -----------------------------------------------------------------------•-----•-_.... .........................................................
Description of Soil ------•- r---------------•-0 -. v:! ------- f��J_Q„a - C0_�!? -----" S U__�Ci s'Ql 4 ---------------------
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Nature of Repairs or Alterations — Answer when app licabie.--- _______-------------------- _................................................................
--------------------------------------------------------------------------------------------------------•-------------------------•---•--•----•--•--•--•----•--------------------------------•-_....._.
Agreement:
The undersigned agrees to install the aforedescribed Individual Sewage Disposal System in accordance with
the provisions of TITIE 5 of the State Sanitary Code — The undersigned further agrees not to place the system in
operation until a Certificate of Compliance has beAn issu d by the board of health.
....
Signed------- s ................................................... ..........................
' �-�� Date
Application Approved BY -23 -----
Date
Application Disapproved for the following reasons: ------•--•---------•-•--•---•-------•---•---•----------------------•------------------------•----........----
Date
Permit No ...... . rI. ------------------------- Issued_ ------ '� �'
Date
THE COMMONWEALTH OF MASSACHUSETTS
BOARD OF HEALTH
:'..OGiC.?40................. OF ..... ,��'. / 37 .. ...............................
At
wrtifiratr of Tontplianrr
THIS IS TO CERTIFY, at e Individu ewage Disposal System constructed ( P05 or Repaired ( )
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(� Installer
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has been installed in accordance with the provisions of TITLE 5 of The State Sanitary Code as described in the
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application for Disposal Works Construction Permit No.___.��'__; ___.�__': -------•-- dated----
THE ISSUANCE OF THIS CERTIFICATE SHALL NOT B STRIKE® AS A GUARANT THAT THE
SYSTEM WILL FUNCTION SATISFACTORY. i
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DATE ................. --•----� --•------••--------------•---- Ins