HomeMy WebLinkAboutApp-Permit-ComplianceTHE COMMONWEALTH OF MASSACHUSETTS
BOARDv OF HEALTH
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Appliratiun for Disposal Works Tonstrnrtiun 1hr' ntit
Application is hereby ade for a Permit to Construct ( ) or Repair ( ) an IndiMual Sewage Disposal
System at: ^ ---- • - ---...................................
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Lo tion -Address r Lot No.
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Owner Add
Installer Address
Type of Buil ng Size Lot ............................ Sq. feet
Dwelling —No. of Bedrooms.._._....... Expansion Attic ( ) Garbage Grinder ( )
Other — Type of Building ............................ No. of persons ............................ Showers ( ) — Cafeteria ( )
Othgr fixtures ------•--------------------------------•------.-------.---.---------------------------------------------------------------•------------------•--------
Design Flow...... _ . b..............................gallons per person per day. Total daily flow ............................................ gallons.
Septic Tank —Liquid capacity/OCA 0 -gallons Length ................ Width ................ Diameter ................ Depth ................
Disposal Trench — No- -------------------- Width .................... Total Length .................... Total leaching area .................. ..sq. ft.
Seepage Pit No ..................... lameter.................... 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 ..... ......... ---•-...fid .........----•--•--------------•-----------------•-----•---........----•---..........__.....---•---•-------------......
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Nature ofirs or tions Ans r wh a licabla.
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Agreement:
r .
The undersigned agrees to install the aforedescribed Individual Sewage
the provisions of )'IT 1E 5 of the State Sanitary C de — The unders edA
operation until a Certificate of Compliance has bVis SSLby then of
Application Approved By..........
Application Disapproved for the
Permit No ... T-165----------------------••-----------
posal System in accordance with
agrees not to place the system in
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_...._.l_._ ...�Date.-� Gy..
Da a
Date
Issued- - D�-----------2..............
ate
THE COMMONWEALTH OF MASSACHUSETTS
BOARD OF HEALTH
Q. .......................... OF... ?M.Qkr-# ...................................................
(Irrtifiratr of Toutplittnrr -
HISW TO CERTIFY, That the Individual Sewage Disposal System constructed ( ) or Repaired
bY- KMA�J
- - _...... - ... ....................
\/ Installer
at.Q..._ C�2EE__�Q .D.�... `�T __.Zi�'!YI n�1�V.-------------------------------------------------------------------------------------------------------
has been installed in accordance with the provisions of TITrE r The State Sanitary
ode_ per je the
application for Disposal Works Construction Permit No._�_.-.�. .... dated/' --. -. 1 ! Zi
PP P �. •-•................
THE ISSUANCE OF THIS CERTIFICATE SHALL NOT BE CONSTRUE® AS A� NTEE THAT THE
SYSTEMA WILL, FUNCTION SATISFACTORY. __ — �/✓,
DATR� .......... � . �--...................................... Inspector__...: �21�11/�'.-.11:_1'...-- ........ ?