HomeMy WebLinkAboutApp-Permit-Compliance�-! Fps/ .......................
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THE COMMONWEALTH OF MASSACHUSETTS
BOARD OF HEALTH
77;5�� ....----....OF...... D�d .............................................
Appliration for Dislinaa1 Works Tottstrurtion ramit
Application is hereby made for a Permit to Construct ( ) or Repair (l-l"'an Individual Sewage Disposal
System at:
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ocation- •dress j/ of No.
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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 ............................ 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___________.__..._.._ ---
Descriptionof Soil-------------------------------------------------------------------------------------------------------------------------
----•-•--------•-----------••-•----•--.....-•--•-----------•---•-----------------•-------......----------------------------•--------------------•- -- ------•-----------------------
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Repair -
Alterations Ans er when/Alicb�_ _-_._-�?���....................... �
Agreement:
The undersigned agrees to install the aforedescribed vidual Sewage Disposal System in accordance with
the provisions of TITIL 5 of the State Sanitary Code unde signed furt-ler agrees t of to place the system in
operation until a Certificate of Compliance has been i ed �j he�rd'tf�li !
Application Approved By._ ._. __..__
Application Disapproved for the following reasons: -
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Permit No ......... `3_� yf�-----------------------
�, ..
Date
Date
Issued- .......... jr:7/ -'jell ...............
Date
THE COMMONWEALTH OF MASSACHUSETTS
BOARD O HEALT '
1 r
/'!. ...............OF......... . .................
Tntifira r of Tootlilia
TH S S O ERTIF -�T e}�iu:v S e D i s p os s
Y _ ------------------------
Inst le
has been installed in accordance with the provisions o I The_
application for Disposal Works Construction Permit T _.`
( ) or Repaired ( 4-K
State Sanitary Cade as deseri ed in the
dated ------ e-- '----
THE ISSUANCE OF THIS CERTIFICATE SMALL NOT BE CONSTRUE® AS A GUARANTEE THAT THE
SYSTEM WILL FUNCTION SATISFACTORY.
DATE...... . �---------------------------•-------•--_..... Inspector--
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