HomeMy WebLinkAboutApp-Permit-Compliance..................
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THE COMMONWEALTH OF MASSACHUSETTS
BOARD OF HEALTH
...................... ........... I ...... -OF .............................
Appliratiou for Dhqvoiial Works TougtrurtiouVam'd
Application is hereby made for a Permit to Construct or Repair an Individual Sewage Disposal
System at:
............
.. ..................................
........... . .
Location Lot No.
t rr ..................................... . r ............
........... I .............................
..................... Address
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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.._.._...._..........__.
Description of Soil ---------------------------------
.....................................................................................................................................................................................................
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Nature of Repairs or Alterations — Answer when applicable ... . ....... /-
07. ea ......................
Agreement:
I The undersigned agrees to install the aforedescribed Individual Sewage Disposal System in accordance with
the provisions of TiLE, 5 of the State Sanitary Code — The undersigned further agrees not to place the system in
A. -
operation until a Certificate of Compliance has been issued by the board of health.
Signed .........................
e ----------------------------------------------------- ------------ D ------------------
Application Approve ....................... ----------
Date
following
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Application Disappro, for the following reasons: ................................................................................................................
......................................................................................................................................... ........................... I ---------------------------------
Date
PermitNo--------------------------•-•-----------------------••--- IssuedL -------------------------------------------------------
Date
THE COMMONWEALTH OF MASSACHUSETTS
BOARD OF HEALTH
.......................................... OF .....................................................................................
(Intifiratr of Tompliattv -
THIS IS TO CERTIFY Tat the Individual Sewage Disposal System constructed or Repaired*
by-------------------
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T Installer
at--• .......... /_4LL
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s
has been installed in accordance with the provisions of TIT he o State Sanitary Co yasdoscribed in the
application for Disposal Works Construction Permit No.&4_12=11Z ................ dated---.,-,-,- , ...............
THE ISSUANCE OF THIS CERTIFICATE SHALL NOT BE CONSTRUED ASA G ARA TEE THAT THE
SYSTEM WILL FUNCTION SATISFACTORY.
DATE-------------------------------------------------------------------------------- Inspector