HomeMy WebLinkAboutApp-Permit-ComplianceTHE COMMONWEALTH OF MASSACHUSETTS
BOARD OF HEALTH
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Appliratinn for Biapanal Works Tonutrnrtiun Vamit
Application is hereby made for a Permit to Construct ( ) or Repair 4 an Individual Sewage Disposal
Systemat
y...1 - ._...._..... - a t M..................................................
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S Locating- Address - or Lot No.
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Owner 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 __ of persons ............................ Showers ( ) — Cafeteria ( )
Otherfixtures .------4-------------------•---.............................................................................................................
er person per day. Total daily flow -------------------------------------------- 1 'r
Width.-•-------_.__ Diameter...-------____-- Depth ........ -.......
........... Total Length .................... Total leaching area----- -------------sq. ft.
Design Flow--------------- ------------- --- Ballo
Septic Tank —Liquid capaci _.__ __.....gall
Disposal Trench — No . ......... ......... Width ......
Seepage Pit No --------------------- Di meter ----- ___-____-_-
Other Distribution box ( Dosing
Percolation Test Results Performed by ......
Test Pit No. 1 ............. .fninutes per inch
Test Pit No. 2--------- -----minutes per inch
........................
Description of Soil ...................................
.. Depth below inlet .................... Total leaching area........ `........_sq. ft.
to ( )
---------------------------------------------------------- Date ---------------------------------------
Dept of Test Pit .................... Depth to ground water ........................
Depth of Test Pit .................... Depth to ground water. .......................
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Nature of Repairs or Alterations —Answer when applicable.____ .__..._ d 1 --
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Agreement :
The undersigned agrees to install the aforedescribed Individual Sewage Disposal System in accordance with
the provisions of T?T�EE 5 of the State Sanitary Code — The undersigned further agrees not to place the system in
operation until a Certificate of Compliance has been i� the%ward iealth.
Signed Fia�th Dffii ' / `nat.....
Application Approved By ----------------------------------------------
Application Disapproved for the following reasons: ___
Permit No.
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Date
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Date
Issued--------------------------------------------------------
Date
THE COMMONWEALTH OF MASSACHUSETTS
BOARD OF HEALTH
.......................................... OF .
Tntifiratr of T.ompliaurr
THIS ISRTIF , That Indy •dual Sewage Disposal System constructed ( ) or Repaired
' `'
Installer d
at------...... .+ .� `..i r`... � --- ------ ------ ............................................................
has been installed in accordance with the provisions ofT TLS 5 of The State Sanitary Cod as described in the
application„ for Disposal Works Construction Permit N Y-=...:2-3 . _ dated__.. _ �/ _. ____ ZAT
-THE ISSUANCE OF THIS CERTIFICATE SHALL PLOT BE CONSTRUE® AS A ARA EE T THE
SYSTEM WILL FUNCTION SATISFACTORY.
DATE.-----------•-------------•---•----.......------•------------------•------------ Inspector.