HomeMy WebLinkAboutApp-Permit-ComplianceTHE COMMONWEALTH OF MASSACHUSETTS
BOARD OF HEALTH
'�...... O F .......... ...........................
y Appliration for Disposal Works Tonstrurtion itamit
Application is hereby made for a Permit to Construct ( ) or Repair ((Y—) an Individual Sewage Disposal
System at
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Location - ddress J/ or Lot No.
.�..t.....� ......... �.Q................_.. p. s.,.5' %,(. � ¢^-�•----------..........�..� .............
.../`:C(/ �.� �.1 Address....X.� 4C.�..
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Installer Address
Type of BuildingSize Lot ............................ Sq. feet
Dwelling —No. of Bedrooms..........................................Expansion Attic ( ) Garbage Grinder ( )
Other — Type of Building ............................ No. of persons ............................ Showers ( ) — Cafeteria ( )
Otherfixtures...................................•---•--..........--.---•-•----............-•-......---•-----....--------...................-•----....---...........
Design Flow ......... :�?.O..........................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 ......... _ .f ... Depth below Total leaching area..sq. ft.
Other Distribution box ( ) Dosing tank 6 OP4
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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Descriptionof Soil ..... 5'e$V&)s6..........................................................•---..........--•---......-------•----............--•-------------........•.........--
--•....................................•-••--•--------••..��....__.........••-•--•-----------.......... . -_... _•-- --- ...... ............
Na re of Repairs orAlterations Answer when app bled ,$ . ..yC �.....wz ...............
' j'-•
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 boao of health„
Application Approved By.
Application Disapproved for the following reasons:
...... . .....
te
-------•----�.�Issued.........._...
� . �'"�...--•--------- �-------------- .
Permit No.............�.���,��^__..._
Date
by
THE COMMONWEALTH OF MASSACHUSETTS
BOARD OF HEALTH
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.................... ........OF... f...... +..............................
(arrtif irate of Tontpliam
THIS IS TO CERTIFY, That the _Indivoual Sewage Disposal System constructed
A 7-
_ �.
) or Repaired (-".0
-.`------------------------------- ------ ------ ----------- - ------------- l___----------------------------------------------------------------------------------------
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 ................................................
THE ISSUANCE OF THIS `CERTIFICATE SHALL NOT BE CONSTRUED AS A GUARANTEE THAT THE
SYSTEM WILL FUNCTION SATISFACTORY.
DATE...-• ' -- •- ' ...:.. F
..._. Inspector ., ° --. ................