HomeMy WebLinkAboutApp-Permit-ComplianceNo............ ..... .. Fps. .._.....
THE COMMONWEALTH OF MASSACHUSETTS
BOARD OF HEALTH
T...... ............ OF ......
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Appliration for Disposal Works Tonstrurtion Frrutit
Application is hereby made for a Permit to Construct ( ) or Repair ( L- rn Individual Sewage Disposal
System at:
-•------•---•------------- W. --------------- ........
e, .Location - Address
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Installer
------....•-----....�?.:.....V v�.....vu...............................
-- or Lot No.
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Address
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 .......... ..................gallons per person per day. Total daily flow...........:!>,3� .. ................ gallons.
Septic Tank — Liquidcapacity ............ gallons Length ---------------- Width ................ Diameter ................ Depth ................
Disposal Trench — No ..................... Width .................... Total Length .................... Total leaching area .................... sq. ft.
Seepage Pit No..... -.1 ------- ..... Diameter.._._. LIV...... Depth below inlet----- \.a........... 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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Descriptionof Soil ............................................................................................
-----------------------------------------------•---------------------------------------------.--•-•-----•......--•--••----------•--•----------••••-••---•••--•-......_......---...---•-----•--.........
Nature of Repairs or Alterations — Answer when applicable ...... VA. ..0.0..............4._—..____....�.zF . _(e ....... all ....
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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 ben issued by the boar h.
-----------
Date
Application Approved BY-----•---ijF
........-•-----•--•--••------....-•-•--...._..---•--•---Application Disapproved for the folloasons:-------•-----------------•-•----•-----------.................-•-----------------------------•--•--•--........._
Permit No.17_ ILY3 _....... ....................
Date
THE COMMONWEALTH OF MASSACHUSETTS
BOARD OF HEALTH
......OF.......�rC-�.� w�
(9rdifirair of Toutplittnrr
THIS IS TO CERTI Y, That thf_ dividual Sewage Disposal System constructed ( ) or Repaired (�
!.
Installer
at .......................... 1........... .............. )e1_9
•-•--------------- S -
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has been installed in accordance with the provisions of TITLEI-- of The State Sanitay odea desc 'be ,the
application for Disposal Works Construction Permit No %P_---••-•-•--.-_-•-- - dated" .----..------ ..
THE ISSUANCE OF THIS CERTIFICATE SHALL NOT BE CONSTRUED ASAI ARANTEE THAT THE
SYSTEM
WILL FUNCTION SATISFACTORY. -- �-
DATE lf....:....2..:1.:.._..._._. ... Ins ector_ '
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