HomeMy WebLinkAboutApp-Permit-ComplianceNo. ..: .........
COMMONWEALTH OF MASSACHUSETTS
BOARD OF HEALTH
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Appliratiun for Disposal Works Tonutrurtiun rtt"btit
Application is hereby made for a Permit to Construct ( ) or Repair ( �Indi�jdual Sewage Disposal
System at:
.........:;3. .............-•••--••-•----......---•-- 60.X_ /D 1A
;�A • _s Location -Address or Lot No.
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Owner ....... ....
�Y� 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 ( )
Other fixtures
Design Flow...... -E`er.-S....................gallons per person per day. Total daily flow --- --. t4 ----------------------gallons.
1
Septic Tank Liquid capacity gallons ength__� .'___. Width. ._...... Diameter ................ Depth ................
Disposal Trench V No. ?v.-j_*&?r$Width...... �......__ Total Length..._ -j -_(O .. -_- 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 ........................
Descriptionof Soil ............................... ...........................................................
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Nature of Repairs or Alterations — Answer when applicable.__...�s5-�.►A �_`________t.(?__•_..S-ev'v
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Agreement:
The undersigned agrees to install the aforedescribed Individual Sewage Disposal System in accordance with
the provisions of TITA L i; 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 theboard of health.
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Application Approved By....--- .. -----------------••----------•--...............-------••-•-------••-----..
ate
Application Disapproved for the f o wing reasons:-•-----•------------------------------------•----------•--------•-------•-•-------•-------......--•---....-----
-------------------------•--...............................---------------------•-----Date ........-----
Permit No.. $8 ` ................................... Issued /QI- I ------------ -
�aze
THE COMMONWEALTH OF MASSACHUSETTS
JF ED 3 45 ` l`T�}2p BOARD OF HEALTH
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(Intifirate of Team rlianrr
THIS IS TO CERTIFY, That the Individual Sewage Disposal System constructed ( ) or Repaired
b.................. --- .' =Y•r 'fx =- = .....-......._
_ Instal}pr
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has been installed in accordance with the provisions of T `i' F r f The State Sanita Code de �j' in the
application for Disposal Works Construction Permit No.�C� .._....... datedo �! -
THE ISSUANCE OF THIS CERTIFICATE SHALL NOT BE CONSTRUED ARANTEE THAT THE
SYSTEMWILL FU CTION SATISFACTORY.
DATE.. . .13 j ................................................ Inspect...........
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