HomeMy WebLinkAboutApp-Permit-ComplianceI7C,00
No................_.. F:aB.............. ............
THE COMMONWEALTH OF MASSACHUSETTS
- BOARD F HEALT
-.
1
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, pplirtttiuu for lliupuo 1 larksA�®rRepair
"i rurtion ritrutit
Application is hereby made for a Permit to Construct ( ( ) an Individual Sewage Disposal
System , �
ca o Addres
.............
v✓" �.. SGL 1
aInstaller Address
Type of Building Size .. Sq. feet
Dwelling —No. of Bedrooms ............... ....._-..._---........... Expansion Attic ( ) Garbage Grinder ( }
Other — Type of Building ............................ No. of persons ............................ Showers ( ) — Cafeteria ( )
Other fixtures ..................................
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Design Flow .... -- ----------------gallons per �daily day. Total flow.._.......--_ .._ ........................ ions
Septic Tank — Liquid' ca.pacityj�_allons Length'��� _ WidthL�a Diameter-._— --___-___ DepthL7_.-_
Disposal Trench — No . .................... Width .................... Total Length ..................... Total leaching area .................... sq. ft.
Seepage Pit No ------- 1----------- Diameter ..... /0....... Depth below inlet --......G ....... Total leaching area. -06.7 -.sq. ft.
Other Distribution box ( ) Dosing ( )
Percolation Test Results Z Performed by...C< / i4-�
Test Pit :\o. I .... �,_..._--- minutes per inch Depth of Tes Depth to ground water ------- ---------__.
Test Pit No. 2_... �2...minutes per inch Depth of Test Pit.__ �f_ Depth to ground water .........................'
Description of Sal) .�"�
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or no.
Address
--�i
Nature of Repairs or Alterations — Answer when
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Agreement :
The undersigned agrees to install the aforedescribed Individual Sewage Disposal System in accordance with
the provisions of 'TT EP " of the State Sanitary Code — The undersigned further agrees not to place the system in
operation until a Certificate of Compliance has be issued by the board_ f hea
Signed.. . ...... --- --
r t"
Application App owed BY •---------------------------- ......
------------------------------ ---------
Date
Application Disapproved for the following reasons-----------------------------------------------------•---------------------------------•-•-----•-......-----_....
........................................................... --- -------
Permit No..---- Issued%!''"'__�-r�
Date
THE COMMONWEALTH OF MASSACHUSETTS
BOARD OF HEALTH
J.0 Ain ................ oF....... .....(� �............................
Trr ifirttV of f omptitturr
THIS IS TO CERTIFY, That the Individual Sewage Disposal System constructed ( or Repaired ( }
bY---------•-•---------••....................•-------•----------------------------- :� ............................................................................
�� Installers r J �U
at -^ D
has been installed in accordance with the provisions of T i IE j of The ktate Sanitary Code as described,the
application -for Disposal Works Constriction Permit No.___.._. ..... dated --------- _--__1------------
THE ISSUANCE OF THIS CERTIFICATE SHALL NOT BE CONSTRUED AS A GUARANTEE THAT YHE
SYSTEM WILL FUNCTION SATISFACTORY.
DA
Inspector