HomeMy WebLinkAboutApp-Permit-ComplianceNo. .... `! J Fmc..........�.......... \
THE COMMONWEALTH OF MASSACHUSETTS 0�
BOARD OF HEALTH
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Appliration for M-41 oo al Workii Tvmitrurti rntit
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Application is hereby made for a Permit to Construct ( ) or Repair ( an Individual Sewage Disposal
Systemat: A 1_bT �- � ....----•-•-----•-•. - -----... ----- ----- •--- ............... - Location - Address............................................ Lot
........................•-•---._Address
Installer Address
Type of Building Size Lot ---------------------------- Sq. feet
U Dwelling — No. of Bedrooms .............................. . . .Expansion Attic ( ) Garbage GrinderPLI ( )
Other — T e of Building No. of persons ............................ Showers — Cafeteria
Pa Other fixtures .____---._.-•--•_________________
W Design Flow ............................................ gallons per person per day. Total daily flow ............................................ gallons.
WSeptic Tank —Liquid capacity ............ gallons 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 ........................................
,141 Test 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 ........................
Descriptionof Soil-----------------------------------------------------------------------------------------------------------------------------------------------------------------------
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Nature of Repairs or AltegLtions — Answer when a licable.__G___ __ ... ................... �(. -I -----------.
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Agreement :
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The undersigned agrees to install the aforedescribed Individual Sewage Disposal System in accordance with
the provisions of TITLE 5 of the State Sanitary CoLe — The undersigned further agrees not to place the system in
operation until a Certificate of Compliance has be iss dKy the boardAoei'-'-;—/ A
Jl ea X
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Dote
Application Approved By-- --------- 7
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Application Disapproved for the following reasons: -------- -•-------------------------------------------------•-------------------------------------------_----
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Permit No.----t. = C �--------------•------------ Issued--------- 7
THE COMMONWEALTH OF MASSACHUSETTS
BOARD OF HEALTH
....................................... OF .............................................................. ......................
Trrtif iratr of Taantplia tta
THIS IS TO CERTIFY, That the Individual Sewage Disposal System constructed ( ) or Repaired ( )
by---------------
Installer
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has been installed in accordance with the provisions of TIT IEt 5 of The State Sanitary Code as described in the
application for Disposal Works Construction Permit No ......................................... dated ----- ...... .._..................................
THE ISSUANCE OF THIS CERTIFICATE SHALL NOT BE CONSTRUE® AS A GUARANTEE AT THE
SYSTEM WILL FUNCTION SATISFACTORY.
Ins
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