HomeMy WebLinkAboutApp-Permit-ComplianceNo. .. ..... ..11:
THE COMMONWEALTH OF MASSACHUSETTS
ARD OF HEALTH
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Applirtttiou for Biavoiial 19orkfi Toustrurtiun ramit
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Application is hereby made for a Permit to Construct ( ) or Repair X an Individual Sewage Disposal
System at d ���
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........................�% ..._ �.................. N ------IV)
T eh
or Lot No.
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r�1(,�Owner QQ Address
aa�.. Q ..� Address
Installer
Type of Building Size Lot ............................ Sq. feet
U Dwelling — No. of Bedrooms --------------------------------------------Expansion Attic ( ) Garbage Grinder ( )
aOther —Type of Building ............................ No. of persons ............................ Showers ( ) — Cafeteria ( )
Pa Other fixtures ------------------------------- - -
W Design Flow............................................gallons per person per day. Total daily flow ............................................ gallons.
WSeptic Tank — Liquid capacity ............ gallons Length ................ Width ................ Diameter ................ Depth ................
x Disposal Trench — No ..................... Width .................... Total Length .................... Total leaching area .................... sq. ft.
Seepage Pit No -----_------------- Diameter .................... Depth below inlet.................... Total leaching area .................. sq. ft.
Z 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 ........................
(i Test Pit No. 2................minutes per inch Depth of Test Pit .................... Depth to ground water ........................
•-------------------------------------------------------------------------------•-------......••.--- .........................................................
0 Description of Soil ............................................................................................................... ----•--•------------------------------------------------
V•------------------------•---------------------------------------------------------------•-------------------.-----------------------------------------------•------------------------------------_---
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U Nature of Repairs or Alterations —Answer when applicable..3"n__,/0 _-------- -- ......................
Agreement:
The undersigned agrees to install the aforedescribed Individual Sewage Disposal System in accordance with
the provisions of ILT . 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 the board of health.
Signed-------------------------------------------------------------------------------------- ------------------
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Date
Application Approved By ........ --o-f-f�-�----- --- ---------------------------------------------- --------•-----------------
Hyea � y7Z---------•-------------------------------------------•----------------•--•------. Date
Application Disapproved for t e f o w ���s�ins:....__..._
•••------------------------------------------•------------------...--••--........................•.................. .................
PermitNo --------------------------------------------------------- Issued --------------------------------------------------
Date
THE COMMONWEALTH OF MASSACHUSETTS
BOARD OF HEALTH
.......................................... OF .....................................................................................
(wrxiifirtt#.e of f�.>nr�t�r�itt�trr
THIS IS T F TIFY, That, -the Individual Sewage Disposal System constructed ( ) or Repaired _(A4 ,,)
,�°_
bY--------- r , .._
lInstaller
at----------- ` f- r'a� --------- �.°f.
has been ins a>lled in accordance with the provisions of TITLE 5 0, T.he State Sanitary Code as described in the
application for Disposal Works Construction Permit No.' � '"- "_ ............. dated ----
71
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THE ISSUANCE OF THIS CERTIFICATE SHAM( BE CONSTRUE® AS A GUARANTEE THA THE
SYSTEM WILL FUNCTION SATISFACTORY.
DATE................................................................................ Inspector ------------------------------------------------------------------------------------