HomeMy WebLinkAboutApp-Permit-ComplianceTHE COMMONWEALTH OF MASSACHUSETTS
BOARD OF HEALTH
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Appliration for Birapuuttl Works Cfunstrur#iun Frrmit
Application is hereby made for a Permit to Construct ( ) or Repair ( an Individual Sewage Disposal
System .l.-- ai�f?2s4.._. �'�6 ....... yam°,
Address or Lot No.
f / f,wner
Address
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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 ( )
Other fixtures
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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De7�pxio I of -Soil.....
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Nature of Repairs or Alterations — Answer when applicable ---------- e= .....
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Agreement:
The undersigned agrees to install the aforedescribed Individual Sewage Disposal System in accordance with
the provisions of TITLF, 5 of the State Sanitary Code — The and rsigned further ag ees not to place the system in
operation until a Certificate of Compliance has be issued b the and ealth.
igned --
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Application Approved By .............. ••• ••• •-- . ••-------•-•-•••-•---•-------•--------•------------•-- `
•- --•----•----- -- • Date- -- .......
Application Disapproved for the f o lowing easons:-----•------••----•-•----•-••----•-••--••---••••---•--------•-•-----••------•--•------•--••----•._......._•--_..
Date
Permit No.- 3 Issued--.,� ��.._....
Date
THE COMMONWEALTH OF MASSACHUSETTS
BOARD OF HEALTH
.............. ..... OF ........
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(9rdifiratr of Tomptianrr
THIS;_IS..TO CERTIFY,, That th :Individual ewa e Disposal System constructed ( ) or Repaired (: )
by..........r/.. (/_ __�r._.....! .G_� f.�l! ...... _____________ ----------------------
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l Installer
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at. _.._./_. G�/.: / /iJ%---------------- ..... ...........................................................................
has been installed in accordance with the provisions of TITLZ 5 of The State Sanitary Code as described in the
application for Disposal Works Construction Permit No--------------------- ----------------------------------------- da.ted.------- .:................................. _......
THE ISSUANCE OF THIS CERTIFICATE SHALL NOT BE CONSTRUED AS A GUARANTEE THAT THE
SYSTEM WILL FUNCTION SATISFACTORY.
DATE.............•...........-----•-----•--------.....-•-------•-•----••-----_-•-•_. Inspector .................. -------_------------