HomeMy WebLinkAboutApp-Permit-ComplianceTHE COMMONWEALTH OF MASSACHUSETTS
BOARD OF HEALTH
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Appliratiun for Disposal Murks Tonstrur#ion 1hrmi#
Application is hereby made for a Permit to Construct ( ) or Repair (.V*) an Individual Sewage Disposal
System at: I 1
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... -»—Owner. ...-•- ................. . � �3 !/J i J.. �.r!r+vl rAdd ('Aed �.
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 ( )
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 arm ..... ............ 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........................
Descriptionof Soil ........................................................................................................................................................................
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U Nature of Repairs or Alter tion — Answer whe applicable...advio...1 ?4:.._1 : 2o..15£f?tto .__ _ �......_.�........_ .
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Agreern t:
The undersigned agrees to install he aforedescribed Individual Sewage Disposal System in accordance with
the provisions of TI'IE 5 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.
Signed.. _\ZGari!►Iftt-......_.... - �?-_ g�%
ApplicationApproved By ............. -- ---•---- .------•-•...--•-•........................... ------------•-----........�� . : ........
ate
Application Disapproved for the f o owin real ns:
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Permit No._U.hl.
..: n .l ......-- -----Issu ........ 1.1 �- ---------�. --
lD
THE COMMONWEALTH OF MASSACHUSETTS
BOARD OF HEALTH
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............ ..................................................................
Trrfifir& of Toutplinurr
H TO CERTIFY, That the Individual Sewage Disposal System constructed ( ) or Repaired (40)
by_f
�% Installer
has been installed in accordance with the provisions of T5�0# The State Sanitar Co as dfc ' d in the
application for Disposal Works Construction Permit No ...... ............ ................... dated__ .-_...S?��.1. /........._._...
THE ISSUANCE OF THIS CERTIFICATE SHALL NOT BE CONSTRUED AS A U RANTEE THAT THE
SYSTEM WILL FUNCTION SATISFACTORY.
DATE............................................................................... Inspector.