HomeMy WebLinkAboutApp-Permit-ComplianceIIVJrCt. 1 iur4 UA 1 t/ I IMt:
No... ....... . ......
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THE COMMONWEALTH OF MASSACHUSETTS /fO�-j
BOARD OF HEALTH
........... TowN'
OF .............................................................................
Appliratinn for Disposal Works Tonstrur#ion Vernti#
Application is hereby made for a Permit to Construct ( ) or Repair ( �an Individual Sewage Disposal
System a
........... ....... �0 -............................I...1.••--------
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--_. ....................
Owner Addres
el ........................................................... ----------------------------------------------------------------------•-------------•-•--•---•----
Installer Address
Type of Building Size Lot._f ecc��__l__�....Sq. feet'
Dwelling —No. of Bedrooms .................. __________________________Expansion Attic ( ) Garbage Grinder (��
Other — Type of Building ____________________________ No. of persons ............................ Showers ( ) — Cafeteria ( )
Other fixtures ._.._.. j_
- ........... Design Flow ------------------------- (f.D0gallons per dTotal daIfgw------- _........�.._
......................gayon�..
Septic Tank — Liquid ca acity7 lions Lep-no—"'07,21,
en .y
h_______Ca._. Width_.Y__�_.. Diameter ---------------- Depth_. ....
Disposal Trench — No_____________________ Width______ Total Length .................... Total leaching area .................... sq. ft.
Seepage Pit No------------ ________ meter......... _r_ Depth below inlet .......... Total leaching area ......... ..sq. ft.
Other Distribution box ( L 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 ........................
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Descriptionof Soil................................................•-------------------•------•-•-------------------------••--•---------------------------•---------------------------•----
-----------------------------------•---------------------•------------------•-------------------------------------------------------•-
Nature of Repairs or Alteration* — Answe whe applicabl __.1`� ___________________... ___...... l______.____._._.._.....
----......�_._ _ �..�. ...__.el-t-� ~. _-------------------
----- ------ -
Agreement:
The undersigned agrees to install the aforedescribed Ind ivi 1 Sewage Disposal System in accordance with
the provisions of TITLE 5 of the State Enviro ental Code = T e undersigned further agrees not to place the
system in operation until a 4Certificate of Comp a ce s bah ed by the board of health.
Signed r.......................�
Date `
Application Approved By -- 7-�--�......
g
- --------------------------------------------------------------------------------------------------- Date
Application Disapproved
Permit No. �� ""'Ir
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Issued------------ - 1 - -----------Date
Date
THE COMMONWEALTH` OF MASSACHUSETTS
BOARD OF HEALTH
TOWN--------------- -OF .----------- -----`^ =.....-.-
�8>C�t�t�CiI�C �Cl-IIrii 1t�4LLJL.� _
THIS IS TO CERTIFY, That the Individua wage Dispos System constructed ( ) or Repaired( �)
by�Tl�h Pr.......��tl�-�--�----------------------------------------------
\ • Ins[a er
at -•-------------•-•--- - U - �l/.�Z------ ... Q y
has been installed in accordance with the provision T�iTLE 5 of The State Environmental Code as described in
the application for Disposal Works Construction Permit No. _-- if -- D ---- - ----------- dated ......... —.. (�_- _..........
THE ISSUANCE OF THIS CERTIFICATE SHALL NOT BE CONSTRUED AS A GUARANTEE THAT THE
SYSTEM WILL FUNCTION SATISFACTORY.
c -/yam
DATE -------------------7- ---7 ... .-�� ...--------- Inspector ----------
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