HomeMy WebLinkAboutApp-Permit-ComplianceI<v0....................... FEs....... .J ..Y?
THE COMMONWEALTH OF MASSACHUSETTS
BOARD OF HEALTH
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Appliration for Disposal Works Toustrurtion Prrutit
Application is hereby made for a Permit to Construct (V,) or Repair ( ) an Individual Sewage Disposal
System at:
..
Location - Address or Lot No.
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Owner
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Installer
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W
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Address
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!: 49ll.gallons Length___- ....... Width.... }'...... Diameter________________ Depth.. .........__.
Disposal Trench — No ..................... Width .................... Total Length .................... Total leaching area .................... sq. ft.
Seepage Pit No -------- /.......... Diameter.._. Depth below inlet ..... 6._........ Total leaching area_-7` t.4.:sc_r#t.G•r•O.
Other Distribution box ( ) Dosing tank
Percolation Test Results Performed by..L-�� ._._ .... 41 LL_��!e :__� C_e Date..7-J_3.:` 3..--.........
Test Pit No. L:5L. ....minutes per inch Depth of Test Pit._ 41."..... Depth to ground water6?�r...
Test Pit No. 2................minutes per inch Depth of Test Pit ............ _------- Depth to ground waterG'?�!t�
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Description of Soil ........... 551�tv_a.......... I9: ZI. -----------------------•-•--------
......................•-------•-----•---------------------------•----...--•--•----••--------............................
Nature of Repairs or Alterations — Answer when applicable..............................................................................................
Agreement:
The undersigned agrees to install the aforedescribed Individual Sewage Disposal System in accordance with
the provisions of TITLE 5 of the State Sanitary Code — The undersigned further agrees not to place the system in
operation until a Certificate of Compliance has beer sued by the boajA ofj4th.
Application Approved By
Application Disapproved for the
q(S--
Permit No ........ _._Sl_--------^ ------ -
---- ------
Date
--------------------------------------------------------------•-_..
/Gate
Issued_ -----_----- l Q ---- 1 _. o.-------Date
-
THE COMMONWEALTH OF MASSACHUSETTS
BOARD OF HEALTH
.......................d.G J OF_1;alC1rll�.i ...
(9rdifirtttr of Toutpliattrit
THIS IS TO IFY, That the Individual Sewage Disposal System constructed (,-<or Repaired ( )
by-----. .------------------------------------------•------------------------•-----........-•--------------•----.......----...------•---•-----•---------
Installer
has been installed in accordance with the provisions of TIT LF 5 of The State Sanitary Code as described in the
application. for Disposal Works Construction Permit No.._.g�.------ --------- dated_._../Z=_ .. ..........
THE ISSUANCE OF THIS CERTIFICATE SHALL NOT BE CONSTRUE® AS A GUARANTEE THAT THE
SYSTEM WILL FUNCTION SATISFACTORY.
DATE..✓' = `........ Inspector...._ ..