HomeMy WebLinkAboutApp-Permit-Compliance*CAJ�
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OMMONWEALTH OF MASSACHUSETTS
BOARD F HEALT
�. ----- ®--.OF........... ................ ...............................................
, pphration for Dispng I Works Tonstrurtion 1krmit
Application is hereby made for a Permit to Construct ( ) or Repair A) an Individual Sewage Disposal
System at: _
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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..........................1 ___..___..._gallons per person per day. Total daily flow ................ 7 .... .zQ........... gallons.
Septic Tank —Liquid capacity..4-0gallons Length -----------_--- Width ................ Diameter ................ Depth ................
Disposal Trench — No . .................... Widt ,/-...... Total Length ._........ _......... Total leaching area .__-•.----.._---..--sq. ft.
Seepage Pit No ........ /........... Diameter..__ 4..... Depth below inlet.........4P...... Total leaching area...? 5-1 --- 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 Soil -_•--------.
------------•------------------•------------•-------------•- •------- ----------------...-------•-•------GSL.
Nature of R •rs or Altera —Answer. when a p i e.
Agreement: U
The undersigned agrees to install the afor cribed Indi
the provisions of TITLE 5 of the State Sanitary ode — The ui
operation until a Certificate of Compliance has }ssued j/y the
Application Approved By....
Application Disapproved for the f olhwvKg reasons: __.�
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idua e age Disposa System in accordance with
le d further ag ees not to place the system in
ealt .
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/.................�......
............................. 1
ate
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Date
Permit No �� < -/------------------ Issued--------- / Q
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THE COMMONWEALTH OF MASSACHUSETTS
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BOARD OF HEALTH
j............................... I.......... OF .....................................................................................
(Intifirtttt of Toutpliaurr
THIS IS TO CERTIFY, That the Individual Sewage Disposal System constructed ( ) or Repaired ( )
by-----------•. -------------------•-•------•------•----------._._.......-•------------•-••--•----------••--.--
Installer
at------------------------------------------------------------------------------------------------------------------- --------•----------•------•------------------------------------------------------
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 CONSTRUE® AS A GUARANTEE THAT THE
SYSTEM WILL FUNCTION SATISFACTORY. /I/��/� ////%jam
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