HomeMy WebLinkAboutApp-Permit-ComplianceTHE COMMONWEALTH OF MASSACHUSETTS
BOARD OF HEALTH
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Appliratiun for Disposal Warks Tonstrurtiun P.rrmit
Application is hereby made for a Permit to Construct (V-4 or Repair ( ) an Individual Sewage Disposal
System at • p
..... :1 ..._.
Location,tjAdd-r-ess... ........... r Lot No. ...... ...............
.............
ow Address
aW•G !" i 6 �(...... r. ......--- . ....................................................... ..................
/ Installer Address
Type of Building -2 Size Lot ................ Sq. feet
Dwelling —No. of Bedrooms............................................Expansion Attic ( ) Garbage Grinder
N Other — Type of Building ............................ No. of persons ............................ Showers ( ) — Cafeteria ( )
P4 Other fixtures ________________________________ ..... _
W Design Flow --_---55 ------------------------------- gallons per person per day. Total daily flow ..... 3 .........................gallons.
WSeptic Tank—Liquid ca.pacity_loOpgallons Length ..... _`_,____ Width ....... Diameter ................ Depth ... ........
x Disposal Trench — No. ....... 1_........... Width ....... ('2 _..__ Total Length......ZZ....... Total leaching area ... 37 A—.- ksq. ft.
Seepage Pit No .......... ........... Diameter .................... Depth below inlet .................... Total leaching area ................ ft.
Z Other Distribution box ( Yj Dosing tank
a Percolation Test Results Performed by ........... 1 ___.._Le&— y .................................. Date... 3_- .......$_ ............
Test Pit No. 1 _._ G Z.minutes per inch Depth of Test Pit...! 5t .......... Depth to ground water ..... t S d............
LL, Test Pit No. 2................minutes per inch Depth of Test Pit .................... Depth to ground water ........................
x
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U 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 TITIE 5 of the State Sanitary Code — The undersigned further agrees not to place the system in
operation until a Certificate of Compliance has been ia by the board o ealth.
Signe ... _-- . . ...
` ate
Application Approved By.... --.•• ....... .... ........................
Date
Application Disapproved for the following reasons------------------•---------•----.....---•-•---•----............---------..........------------------------......
..................•---_..........._.............._.........---...................__..............................................._.......--_....._.................. _........
Permit No..� ..`.11 ......................... Issued.--•-Y.��. 1..
THE COMMONWEALTH OF MASSACHUSETTS
BOARD OF HEALTH
................... OF .......... /�;_ .........................................
Trrtifirate of f1 omptianrr
THIS IS TO CERTIFY, That the Individual Sewage Disposal System onstructed Y'_ .. Repaired ( )
by.. 16- .............. , I t .......................
4., „� - z - , - -
�5
11nstaller r
s
at�, r--------. �:.. / f/ ' .... ........................................ ................ ---
has been installed in accordance with the provisions of TITLE 5 of Th `"State Sanitary ode( as escribed in 'the
application for Disposal Works Construction Permit No. ............... dated__ -_
THE ISSUANCE OF THIS CERTIFICATE SHALL NOT BE CONSTRUE® AS A GUA ANTES THAT THE
SYSTEMA WILL F"CTS N SATISFACTORY.
DATE... . • ----