HomeMy WebLinkAboutApp-Permit-ComplianceY �Np.. .. ......
THE COMMONWEALTH OF MASSACHUSETTS
BOARD OF HEALTH
OF...............................................•-•-••..._.........•-•••-....•••-••.•••--
Aplifiratioo for m 0 1 Works (foustrurtiourprrmit
Application is hereby made for a Permit to Construct ( ) or Repair ( Individual Sewage Disposal
System at: �- r �� ®.._ t ,q5A � 1
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�.. .......Location -Address { _ �j _---------- --- Lot No.
Owner Address
fh., e
Installer Address
Q Type of Building Size Lot _-------------------------Sq. feet
U Dwelling —No. of Bedrooms -------------------------------------------- Expansion Attic ( ) Garbage GrinderPL4 ( )
'L Other — T e of Building No. of persons ............................ Showers — Cafeteria
Other fixtures ----------------------------------•---- -
W Design Flow -------------------------------------------- gallons per person per day. Total daily flow ............................................ gallons.
WSeptic Tank — Liquid capacity ............ gallons Length ................ Width ................ Diameter ................ Depth ................
x Disposal Trench — No ..................... Width .................... Total Length .................... Total leaching area .................... sq. ft.
Seepage Pit No ..................... Diameter .................... Depth below inlet .................... Total leaching area .................. sq. ft.
Z Other Distribution box ( ) Dosing tank ( )
'-� Percolation Test Results Performed by .......................................................................... Date ........................................
aTest 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 ........................
-•-•--------••--------------------••-•--------•---...------•-------------------------------......--•. �-g j`
O Description of Soil ......................................... ,� L(�%�� r 1 r"...............................
W..---•--------------•------••----••---------------••-•••------•--••---•••-•----•------•...----------------------•--•----••-----------..........................................................
VNature of Repairs or Alterations — Answer when applicable........................................................•.._.___._..._..........._._.._........
Agreement:
The undersigned agrees to install the aforedescribed Individual Sewage Disposal System in accordance with
the provisions of TITS 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 ued by the b d of health.
Sign ........... .................... ;................................................. .. Zi1a.
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ApplicationApproved By ..... . ........ ......---•..............• ••------------•--•-..............- u---••------
te
Application Disapproved for the following rea ons: ••-• - ---- _------_----------------------------------------------- ---•-•---•-..._......
-------------•••---••••-••---•-••----•---•-----••--•-----._.....-•--•-------------•-------------•--------•------••••--•-•---•--•--•--•-••••-----•••-•------•-••---•- •----
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Permit No.--- �-----------•-------------------------------- Issued ........................
--
Date
THE COMMONWEALTH OF MASSACHUSETTS
BOARD OF HEALTH
.......................................... OF ............. .......................................................................
(Irrtifiratr of TOMPHaurr
THIS IS TO, CERTIFY, That the Individual Sewage Disposal System constructed or Repaired
t
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/ Installer
at---•------• - f f -'fir= 1�� G . / _ _
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has been installed in accordance with the provisions of TIT ER 5 of The to Sanitary Code as des ribed in the
application for Disposal Works Construction Permit No.__ _=_�__:�.
�' dated.-
THE ISSUANCE OF THIS CERTIFICATE SHALL NOT BE CONSTRUED AS A ARANTEE THAT THE
SYSTEM WILL UN TIONc SATISFACTORY.
DATE ......... Inspector-Tf `
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