HomeMy WebLinkAboutApp-Permit-Compliance6 41 �' o<oyLQ - 14 -
THE COMMONWEALTH OF MASSACHUSETTS
BOARD OF HEALTH
_ .. ................... OF .... �7/4 7 ..... ............... .....................................
Appliration for jBisposal Works Cann -sunt#' n V Mi#
Application is hereby made for a Permit to Construct ( ) or Repair an Individual Sewage Disposal
System at:
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tion Ad ess or Lot No.
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---- 0-4 .. �,_��°`� 1. �.'.................................... --- � � ... ��� �-..................-•---................_................
- Owner Address
•-- - ' �Q ' Q lir ............... ----------------- ---------
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s�-•----•.............•.•.... ._.... ...- ......
Installer Address
Type of Building Size Lot ............................ Sq. feet
Dwelling —No. of BedrODosing
......................................Expansion Attic ( ) Garbage Grinder ( )
Other — Type of Buildi.................... N . of persons ............................ Showers ( ) — Cafeteria ( )
Otherfixtures ...... .....................................-----.------------- ._._..................------................._............._.
Design Flow ................................ to r person per day. Total daily flow._..._........._..___...___.................gallons.
Septic Tank — Liquid ca.paci.... ns Length ................ Width ................ Diameter................ Depth ................
Disposal Trench — No..._......W' th.................. Total Length .................... Total leaching area .................... sq. ft.
Seepage Pit No ---------------------er .................. Depth below inlet .................... Total leaching area .................. sq. ft.
Other Distribution box ( )Dosing tank ( )
PercolationTest Results rmed bY•......................•-••-•-••--•------•••------•--•...............-•--• Date ........................................
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........................
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Descriptionof Soil ...........................................................................................
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Nature of Repairs or Alterations —Answer when applicable. 1... .......................:;....� ...7? - -----
Agreement:
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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 been issued by�jt a boar44 health.
Application Approved By-----.-.--.
Application Disapproved for the
.... ..........f..:�j �Y
Date
Permit No..t�..t�...!._L.T........... ..... .......... _ -- .... ............ Issued. .151 gDF....._
Date
'A' r THE COMMONWEALTH OF MASSACHUSETTS
BOARD OF HEALTH
.............................OF. `....'v. ���-........................................
arr#ifirtt r ,af Taunt rlittnr�e
THIS IS T0,,C_rRT1 That the Individual Sewage Disposal System constructed ( ) or Repaired (L,4'
b i� .... > ..L!!.`.::.... Rfi..1........................
Y--•----.�..�.�.... -.c1-."� '1 �• r 1;�..J „l� 11�-(% Inatalle�--� �'`9--------..`f`-.'-.-1--•--------------•---........... ..---........_...._.__..._
.........,,..... ..................."._. ........... _.......... ._...... ...... ............. . =--- -----....------------••------- ••-----•------••-----.....
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has been installed in accordance with the provisions of TI,T '"� j, of The State Sanitary ,ode asrdescrib�d i the
application for Disposal Works Construction Permit NO. �::.. ___ ` .................. dated
THE ISSUANCE OF THIS CERTIFICATE SHALL NOT BE CONSTRUED AS -A',GUARANTEE THAT THE
SYSTEM WILL FUNCTION SATISFACTORY.
DATE:=�..'?!�3r............................................. Inspectorr....�i�tt"��
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