HomeMy WebLinkAboutApp-Permit-ComplianceTHE COMMONWEALTH OF MASSACHUSETTS
_ BOARD OF HEALTH
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Appliratinn for Disposal Worko Cnnns#rnr#ion Famit `'AFj P _2�
Application is hereby made for a Permit to onst.0 t (y_) or Repair ( ) an Individual Sewage Disposal
System at •
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owner /J� ��jdress
..................................... /.._.. EL..I-Y-Z .. ei�? 5? !Z ........... �C.�. a�. .. .
Installer Address
Type of Building Size Lot .... la, g. k ......Sq. feet
Dwelling —No. of Bedrooms ...................S._........_............Expansion Attic ( ) Garbage Grinder ( )
`k Other—Type T e of Building No. of persons ............................ Showers
Pk � YP g •----•...................... P ( ) —Cafeteria ( )
dOther fixtures................•-•-----•---.....---......--•--......:..--••-----........--•-•-••-•--•--............-•--•-----•-------...............----•--•---......
Design Flow................�9..5.............._..- gallons per person per day. Total daily flow ......_........�:��............... gallons.
�G Septic Tank —Liquid capacity_l. allons Length ................ Width ................ Diameter................ Depth ................
Z Disposal Trench — No.......:L......... Width ................ Total Length ..... 1 ....... Total leaching area.. 4QO......sq-€t-
'�: Seepage Pit No ........ 1'-.... Diameter .................... Depth below inlet.................... Total leaching area .................. sq. ft.
Z Other Distribution box ( K) Dosing tank ( ) 6PD
Percolation Test Results Performed b
Y .... ✓%... .............. Date ��l' . ............
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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U Nature of Repairs or Alterations— Answer when applicable...............................................................................................
Agreement
The undersigned agrees to install the aforedescribed Individual Sewage Disposal System in accordance with
the provisions of TITLE 5 of the State Sanitary Code — The undersigned further agrees not to place the system in
operation until a Certificate of Compliance has ben issued �brdof health.Signed..-� ..... --- - ...��----
Application Approved BY ......... ............................................................
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Date
Application Disapproved for the follonng reasns:.....................................................................................................
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Permit No.------ ....._ d.l._.................... Issued.-...... 31&10...._ Dau._....
Date