HomeMy WebLinkAboutApp-Permit-ComplianceL -17V ......
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THE COMMONWEALTH OF MASSACHUSETTS
BOARD OF HEALTH
............................. ............. OF_ ........................................................................................
Appliration for Disposal Works Tonstrurtion Vrrmit
Application is hereby made for a Permit to Construct or Repair 06 an Individual Sewage Disposal
System atN
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/ Aildress or Lot No.
A � 2 tion A ................................... .......... . .........
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0 ess
LA. _.-I ........................................ ..................................................................................................
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............... 6 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. 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...
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Nature of Repairs or Alterations — Answer when applicable...x ........ -A ------- ............... 'L
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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 .is ed by the board of he th
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igne; .. .. ... ..... ... 1__9 .. .... . . 1 .............................
Date
Application Approved By •...... .. ........ ........... ................................................... ........
D e
Application Disapproved for the following reasons: ................................................................................................................
Permit No.
Issued. ..................... _
Date
THE COMMONWEALTH OF MASSACHUSETTS
BOARD OF HEALTH
Date
.......................................... OF .....................................................................................
Tntifirate of (foutpliattrr
THIS IS T_O-, Q�R7XY, That the Individual Sewage Disposal System constructed or Repaired (A)
...............................................................
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by -------------------- /-�- ..................... �.. ----------
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at. ...........................
atate . Sanitary Code d - the
has been installed in accordance with the provisions of TI IE, 5 0 s7cbe��n
application - for Disposal Works Construction Permit No .... e_0 - — ----- ST!Z_-�S... dated -------- ......................
THE ISSUANCE OF THIS CERTIFICATE SHALL NOT BE COMSTRUED AVA GUARkNTEE THAT THE
SYSTEM FU CTI ATISFACTO
WILL L 'RY.
DATE
.............. I ......... Inspector.10 A - ----- ..........................................
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