HomeMy WebLinkAboutApp-Permit-ComplianceTHE COMMONWEALTH OF MASSACHUSETTS
BOARD OF HEALTH
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Appliration for Disposal Works Tonstrurtinn Vautit
Application is hereby made for a Permit to Construct (X'or Repair ( ) an Individual Sewage Disposal
at
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1 Location -Address or Lot No.
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n....�� '7/ Address
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a................... E:; ::✓F----.-- Ins all rL - Address
Type of Building Size Lot ............................Sq. feet
Dwelling — No. of Bedrooms ................................. ...........Expansion Attic ( ) Garbage Grinder ( )
Other — T e of Building No. of persons .................._-_----_ Showers ( ) — Cafeteria ( )
Q, Other fixtures ----------- ----------------------•---- -
W Design Flow ...................•--. ' ._gallons per person per day. Total daily flow -------------------------------------------- gallons.
WSeptic Tank — Liquid capacity/crZ llons Length-___-----_-__- Width ................ Diameter ................ Depth ................
x Disposal Trench — No- -------------------- Width .................... Total Length .................... Total leaching area .................... sq. ft.
Seepage Pit No --------------------- Diameter .................... Depth below inlet .................... Total leaching area .................. sq. ft.
Z Other Distribution box ( ) Dosing tank ( )
Percolation Test Results Performed by.......................................................................... Date ........................................
aTest 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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0 Description of Soil ........................................................................................................................................................................
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UNature of Repairs or Alterations — Answer when applicable ------------------------------------------------------ _.........................................
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Agreement :
The undersigned agrees to install the aforedescribed Individual Sewage Disposal System in accordance with
the provisions of TITi.s�. 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...................................................................................... ................................
Date
Application Approved By �1 -•-------------------------------- ----------------------------------------
77
---� � F<;.,�k,n Date
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Application Disapproved for t e:�odwi g,=reasQns:----•---•••-•-•------------•---•--•---•-•-------••--•--•---------•-••---------------•..........................
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s Date
PermitNo --------------------------------------------------------- IssuedL -------------------------------------------------------
Date
THE COMMONWEALTH OF MASSACHUSETTS
BOARD OF HEALTH
-.......,7/7.7-s1..r i ...... O F......... ... .: c......................................
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Trriifirtt >af Toutpliattrr
THISJSIf0 CERTI . That the/1' ividual Sewage Disposal System constructed ) or Repaired ( )
instaner ,
at... 4e4a;. ...; � ---- r
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has been installed in accordance with the prow of T T , 5 The State Sanitary Coeb ilte.
application for Disposal Works Construction Permit No.,,�.� t� ............. dated__ �°�" ""'._;,---------,��.�._t.....-
THE ISSUANCE OF THIS CERTIFICATE SHALL NOT BE CONSTRUED AS A GUARANTEE THAT THE
SYSTEM WILL FUNCTION SATISFACTORY.
DATE................................................................................ Inspector.