HomeMy WebLinkAboutApp-Permit-Compliance011
No.. F�s.� . ...............
THE COMMONWEALTH OF MASSACHUSETTS
B ARD OF HEALTH
Gl
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App ir�atiun for Dish Sal urku Tonstrnr#ion jkrmit
Application is hereby made for a Permit to Construct �'C) or Repair ( ) an Individual Sewage Disposal
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Installer Address
Type of Building Size Lot ............................ Sq. feet
Dwelling —No. of Bedrooms............................................Expansion Attic ( ) Garbage Grinder ( )
Other -- Type of Building ............................ No. of persons............................ Showers ( ) — Cafeteria ( )
Otherfixtures ------------------------------------------------------------------------------------------------------------------------------------------------------
Design Flow ................... 9_ <. --------gallons per person per 'day. Total daily flow ............. ...............................gallons.
Septic Tank — Liquid' capacit/BZgallons 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. I................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........................
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Description of 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.
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kigned...................................................................................... ............ Dat.e......
In Date
Application Approved By ................ . ,zL,J .✓Z�-----(-
..-- -�------------------------------------------------------ Date
Application Disapproved for the following reasons:....
Date
PermitNo ....................................................... _ Issued_ ........................
Date
THE COMMONWEALTH OF MASSACHUSETTS
BOARD OF HEALTH
<:...r.<.c.<C. r ....OF.. ... f . ..........'....................................................
Trrtifira6 of Tompliaurr
THIS IS T9 CERTIFY, Thgt/the Individual Sewage Disposal S7stem constructed (-�:) or Repaired ( )
b< ��-•-•-----_.. •......................................................
� Installer
at........ �,�'� -----.--r%.
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has been installed iri accordance with the ovisions of TITLE 5 of The re Sanitary Code as: described in the
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application for Disposal Works Construction Permit No.__: j�'_ ___�';:/_ �...._....... dated__._ ______1...___., �-----------------
THE ISSUANCE OF THIS CERTIFICATE SMALL NOT BE CONSTRUE® AS A GUARANTEE f HAT TIME
SYSTEM WILL/fUNCTION SATISFACTORY.�%
DATE .................. .... Inspector