HomeMy WebLinkAboutApp-Permit-Compliance1Vo.7114617
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THE COMMONWEALTH OF MASSACHUSETTS
BOARD101IF4W.
HEALTH
- .OF......aj.. .7_11 .................................
Appliration for Disposal Works (fnnstrurtion Frrutit
Application is hereby made for a Permit to Construct (-K) or Repair ( ) an Individual Sewage Disposal
4��Sy�em at:
- _�........_ :: 40_-7--J-.. e-- 7
cation - Ad rens--•-----------------------•-•-•----------. or Lot No.
......................-•-../ ....... ---••----•••- -•--------•-••••-•--•-•-------••-....___...__•---._•--
V/ - Owa*r ,moi i� . / Address
Installer Address
Type of Building Size Lot____________________________ Sq. feet
Dwelling —No. of Bedrooms _____________2:- ..................... 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 Soil ............................
.................................................... -------------------------------------------------------------------------------------------------------------------------- 7 ------------
Nature of Repairs or Alterations — Answer when applicable ..................................................................................
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Agreement :
The undersigned agrees to install the aforedescribed Individual Sewage Disposal System in accordance with
therovisions of TITi.;
p 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.
ed ...... -------------------------•--------------------------
------•-----•-•-----•-
Dat
Application Approved By... --- s�--------------------- ••...--------'�/�.��y._....
Application Disapproved for the following reasons: ----•-----------------------•-------•------------------•-----•----------------------------------------•-----•--
--------------------------------•-••---------- ......•-•.._.....•-••••----••--••••-•-..........---.....••------------------------------•---•------------------------------------••--•••-----•-....------
Date
PermitNo --------------------------------------------------------- Issued .......................................................
Date
THE COMMONWEALTH OF MASSACHUSETTS
.,,. OARD,, Q)F HEALTH ,
. OF... ....................................
�rr��iirtt#�e n� f�laut�li�anrle
THIS IS TO CERTIFY,J-At teal Sew g Disposal System constructed ( ) or Repaired ( )
by..._•-_... . f... ..---•--•--•---••................. E• ..................
r `✓ .... s t f s f§ 1 r /i«.;{
ns
at----•_---- •--_•------•------•------_--•. •--•-•-------•-------•--_... --• ------ ------ ---- ---_/ - ------ ------
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has been installed in accordance with the provisions of TITLE'> of �Ijie to Sanitary ,.odea s tlesCi* eE in the
application, for Disposal Works Construction Permit No.__ � __ ____._.. dated. -/
ISSUANCE OF THIS CERTIFICATE SHALL NOT BE CONSTRUED AS A GUARANTEE THAT THE
SYSTEM WILL FUNCTION SATISFACTORY.
DATE................................................................................ Inspector.