HomeMy WebLinkAboutApp-Permit-ComplianceNo........... /:..F�$....1... s............. .
THE COMMONWEALTH OF MASSACHUSETTS
BOARD OF HEALTH
...................... ............... VOF..... \�...-...-..............:------....-----------------..----------------•-------------
Appliration for 11ispasal Workii Tomitrndiun lirrmit
Application is hereby made for a Permit to Construct
System// at:
cat' n s
Addres
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Installer
) or Repair ( ) an Individual Sewage Disposal
- O r- V313 4 -LSP
or Lot No.
Type of Building
Dwelling — No. of Bedrooms ............................................ Expansion Attic
Other — Type of Building ____________________________ No, of persons .......................
Address
Address
Size Lot ............................ Sq. feet
Garbage Grinder ( )
Showers ( ) — Cafeteria ( )
Otherfixtures-----------------------•----._......---------------•--•-----._._..._...._..
Design Flow ............................................ gallons per person per day. Total daily flow ............................................ gallons.
Septic Tank — Liquid capacity ............ gallons 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 ........................
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Description of Soil________________________________________________
-------------------------------------........................................................ ---••-----•-- • •-•••••-------•--------•--------•------...--------. ..........
Nature of Repairs or Alterations — Answer when applicable ____..........
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Agreement : V
The undersigned agrees to install the aforedescribed Individual Sewage Disposal System in accordance with
the provisions of TIT?•` 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 By....
Application
y.__.
Application Disapproved for the following reasons:..
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Permit No----- 6-- !..........
.... .............. .
. ... .. .
...............
Date
issued --------------- Il_�- --
Date
THE COMMONWEALTH OF MASSACHUSETTS
BOARD OF HEALTH
7 J.. ti . ,
i .......
...........0F...... .
C�ir�#�f irtt�le of f��ant�rlittnrr
THIS IS TO CERTIFY, That the Individual Sewage Disposal System constructed (° or Repaired
by-••-•-- ----- r--•--•-----•--------•---•....................•-••---•-.....-------- •--•-----••--------•--••----••-••----•----•--•-•--••----.....-••-----............--••-------••••-
j , Installer
at ........
r :::. f = ------------------------•----------•-•-----...•--•--•-•...--------------------------------•-•.........._•-•-•--........__._.._.._
has been installed in accordance with the provisions of TITLE 5 of The State Sanitary Code as described in the
application for Disposal Works Construction Permit No ....... +'.. dated_-. .....=r
THE ISSUANCE OF THIS CERTIFICATE SHALL NOT BE CONSTRUED AS A GUARANTEE THAT THE
SYSTEM WILL FUNCTION SATISFACTORY.
DATE. `~' / %'...-•----•----••-----...--•------•- Inspector�%!�. /
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