HomeMy WebLinkAboutApp-Permit-ComplianceNo.4.$..gi...... FEB 1- d.0
THE COMMONWEALTH OF MASSACHUSETTS
BOARD �1OF HEALTH
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Appliration for Disposal Workii Tonstrnrtion r.rrmit
Application is hereby made for a Permit to Construct ( ) or Repair an Individual Sewage Disposal
System at:
Location . Address or Lot No.
r--•-------------•----------------•-------------_---•----•-------•---------.------- -----.-..---•------•----•------------------------.--
Owner 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 ........................
Description of Soil.........
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Nature of Repairs or Alterations — Answer when applicable._.-_. fCpp---- G.sr...... Q_ BOY--------.�-----�sQF c -.•.roc
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Agreement :
The undersigned agrees to install the aforedescribed Individual Sewage Disposal System in accordance with
the provisions of TITL% 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 1 alth.
Signed-. C- f L --• - ---------------------- ----g --� j/ �
Application Approved By....------------•-•-•---••-------••------------•--••----•-......---•......... .•zS t�
Application Disapproved for the f of ing re ons---------------------------------------------------------------•------------------------------------------.......
........................ -------------................... •--------------•-----•-------.....----•--------------------•--------------•-•-•-- ---•------•------r------•-------------• ---•--
Date
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Permit No.p—a�l ..................................... IssuQ.(1) ------------
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THE COMMONWEALTH OF MASSACHUSETTS
HEALTH
-
BOARD OF Hlie
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o_--flit)............................OF..YIRM. 61N.77i ........................................................
Trrtifiratr of Tomlrlitutu
THIS CERTIFY, That the Individual Sewage Disposal System constructed ( ) or Repaired
byl�lli�1 C = x.! S.I 1Ca....._...--•---•-----------------•--------------.................................................................................................. --------------------------------------------•---------•-•------------......................------.
�/ Installer
at. S V� t11 Y.Eulzt�, 11 .0 TV -------- ---_------_- --•---------------•-----------•--------------------------------------------
-
has been installed in accordance with the provisions of T;LT LT, �rr,lof The State Sanitary- ode a xil�g the
application for Disposal Works Construction Permit No..� �1��.................... dated _���iG� _'_t:_:_ �./_ �..........
THE ISSUANCE OF THIS CERTIFICATE SHALL NOT BE CONSTRUED AS A GUARANTEE THAT THE
SYSTEM WILL FUNCTION SATISFACTORY.
DATE............................ ............................... Inspector----------------------------------------------------