HomeMy WebLinkAboutApp-Permit-ComplianceFEE .............
THE COMMONWEALTH OF MASSACHUSETTS
BOARD OF/ HEALTH
011!
10
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Appliration -for Uh5potiai Works Tonstrurtion P-ermit
Application is hereby'made for a Permit to Construct or Repair an Individual Sewage Disposal
System at:
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........ Installer
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Address
M
d Type of Building Size Lot_,e'?� Sq. feet
Dwelling — No. of Bedrooms ----- .0 ..................... Expansion Attic Garbage Grinder
P-4 Other — Type of Building -------------- . .......... No. of persons ----------- 4 . ........... Showers Cafeteria
P4Other fixtures ________________ -______________ ------------------- --- -----------------------------------------------------------------------------------------------
Design Flow___.______1795 _____________________gallons per pet -son per day. Total daily flow -------- Z�Z> --------- ---------- gallons.
P4 Septic Tank —Liquid capacit/AkPgallons Length___.___"'_____ Width_____ Diameter______--______ Depth ----- — -------
Disposal Trench —No No. --------- Width ...... or - — ------- Total Length______`-'__ - Total leaching area ------ !:7---- sq. f t.
...... --- ---
Seepage Pit No ... Diameter ..... ZZ ......... Depth below inlet.S! Total leachingareL& ft.
Z Other Distribution box Dosing ttj;ik
D at ....... foloz,
Percolation Test Res Its Performed by_7A_&( f/A D
0.
Test Pit i 1�✓ .-.-minutes per inch Depth of Test Pit --- 64;q ----- Depth to ground water_______________- ......
1:14 Test Pit No. 2_r&1V ---- minutes per inch Depth of Test Pit .... ......... Depth to ground water ........
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0 D t f Soil �*/ & --- i Z _9
W, ------ - -------- - ---- -- .... . .
S—Scro . ..... - --------
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A
Z'n ---- Am -------- ---- ------- W. 1
U Nature of Repairs or Alterations —Answer when applicable- _r=!► ------------- ------------------------------------------- ---------_-----------
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Agreement:
The undersigned agrees to install the aforedescribed Individual Sewage Disposal System in accordance with
the provisions of Article XI of the State Sanitary Code — The undersigned further agrees not to place the system in
operation until a Certificate of Compliance has been its tied by the board of health.
I nsD
SSlg ... . ........... ---------- -- ----
igned ..... .... . .. ...... ... - ------_------
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Application Approved By ... 8 ----------1------ -------- ------------------------------------------------ ..... . Da e
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Application Disapproved for the followin reasons- ----------------------------------------
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Date
PermitNo --------------------------------------------------------- Issued ------------_------------- --_------------------__
Date
THE COMMONWEALTH OF MASSACHUSETTS,
BOARD OF HEALTH
K
J
.......................................... 0 F ................................. ...................................................
( ntifiratr of WAT11mlitiaurr
THIS IS_.TO C TIFY"That the Individual Sewage Disposal System constructed k) or Repaired
by..- ............ -------------------- -------------------------------------------------------------- * -------------
--------- -----
Install
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at --_--------_---------- ... 0./ ----- �j�; ---Al- -------- ----------------------------
has been installed in a'ccordanceith the provisions of icle XI of ?;tie�Sttat�eSaz Co' eas described in the
0 'ary
application for Disposal Works Construction Permit No-_____ dated_____ F__ ---------
R-AS ISSUANCE OF THIS CERTIFICATE SHALL NOT BE RUE® �T�� THE
SYSTEM WILL PNCT!PN SATISFACTORY.
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DATE ------ --- --------- -- -- . ................
0 ------------------------------------------ Inspector