HomeMy WebLinkAboutApp-Permit-ComplianceNo..l1`.?r. �..,..� Fes$.. I...--•--......
THE COMMONWEALTH OF MASSACHUSETTS
BOARD OF HEALTH
...................... .................... OF .........................................................
.... .............
Appliration for Disposal Works Tonstrurtionrrmit
Application is hereby made for a Permit to Construct
ry System at
or Repair (�) an Individual Sewage Disposal
r/ )_T S 1 -- 6 J
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_- Address
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 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 ........................
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Description of Soil...
Nature of Repairs or Alterations — Answer w n applicable "�../�.__. __,�(�J ._..-..��.L:
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Agreement:
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Agreement :
The undersigned agrees to install the aforedescribed Individual Sewage Disposal System in accordance with
the provisions of TIT1E 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 boar4^,of health.
Application -Approved B
Application Disapproved for the f ollowifyy reasonsl...
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Date
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Permit No -------- -U j--------------------------------------- 3
Issued -
Date
THE COMMONWEALTH OF MASSACHUSETTS
BOARD OF HEALTH
.......................................... OF .....................................................................................
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Tby �S TO CERTIF-Y1, That the Individual Sewage Disposal System constructed ( ) or Repaired,)
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instauer
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has been installed in accordance with the provisions of TITLE 5 0 he State Sanitary Code s de crib- d in the
application for Disposal Works Construction Permit No.__ �. __-_------- dated_._. __ _/ �__-�...r
THE ISSUANCE OF THIS CERTIFICATE SHALT. N C STRUE® AS A ANT HAT THE
SYSTEM WILL FUNCTION SATISFACTORY.
DATE........... /� �j �J._-•--------------------•---- Ins - - -- ------ --• ----..............................