HomeMy WebLinkAboutApp-Permit-ComplianceTHE COMMONWEALTH OF MASSACHUSETTS
BOARD OF HEALTH
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Applutt#iun for Disposal Works Tonsirurtiun rrrmi#
Application is hereby made for a Permit to Construct ( ) or Repair (4) an Individual Sewage Disposal
System at:
Location - Address V or Lot No.
......................---------
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--- Owner ddress
_.... . --• .................................................................. ......--•- •....... 35'o Ccl» cSM
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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............................................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........................
Description of
--------------------------- -------------------•------•--------------•--------------....--------------.........--� J. ----....--•--......--------•-•---------- .........----
Nture of Re airs or Alterations —Answer when applicable..Xar ._{Z .__ ._ _ �'G
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Agreement:
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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.
Application Approved
Application Disapproved for the
Signed.
reasons:....
Permit No.?_' 7 --•-•-- --•-•-•--• .................
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............•..... _.........D�___....
Issued_....•. ----.. �Q�.!9 5..........
- 'Date
THE COMMONWEALTH OF MASSACHUSETTS
^�n BOARD OF HEALTH -^"—``
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(Irrfifirtt i of (autttpfittnrr
H �S TO CERTIFY, That the Individual Sewage. Disposal System constructed or Repaired
by-# • --:.------------------•---...................------------------.....--•-- ......_......._......----..... ......:......_..-•---. ..:.....
Installer
at_t�!� --- . �i � DEtt�5..��'i�.q/f •-�!��! ---- e�Ttc i�!I'OliTH-------------_.......----------------------- - •------- -- •----- - ----- -- - ...__..
has been installed in accordance with the provisions of T�,TLE � f The State Sanitary de as scri d
application for Disposal Works Construction Permit N0-- - ----7_ -------------------- dated> ................. __. ..i.. .
THE ISSUANCE OF THIS CERTIFICATE SHALL NOT BE CONSTRUED AS �"RANTEE THAT THE
SYSTE WILL FUN//CTI/pON SATISFACTORY. �A.�
DATE �kP / _.. Inspectors .�l......................