HomeMy WebLinkAboutApp-Permit-ComplianceNO.— ------------ - ----- - THE COMMONWEALTH OF MASSACHUSETTS
V
BOARD OF HEALT
. ....... .....OF..
10 .. ..............................
Appliration for Mspmial luorhoZonstrurtion Prrmit
Application is hereby made for a Permit to Construct an Individual Sewage Disposal
System at:
C46, ........... ....
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or Lot No.
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0 , Address
'K
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Installer Address
Type of Building Size Lot ............................ Sq. feet
Dwelling — No. of Bedrooms ----- c2 ...............................Expansion Attic ) Garbage Grinder ( )
Other—Type of Building ............................ No. of persons............._._....._...... Showers ( ) — Cafeteria ( )
Otherfixtures ---------------------------------------------------------------------------------- ---------------------------------- ................................
Design Flow ..... �S.. _?. J ......................gallons per person per day. Total daily flow ........ ..........__......gallons.
Septic Tank —Liquid capacity ........... gallons Length ................ Width................ Diameter ---------------- Depth....._........_.
Disposal Trench — No. --------_-_------ Width .................... Total Length............._._..__ 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. 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 -------------------------------------------------------
Agreement:
The undersigned agrees to install the aforedescribed Individual Sewage Disposal System in accordance with
the provisions of T I TIL 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.._..
Application Approved By -------------------------------------------
Application Disapproved for the following reasons:
Permit No.
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Date
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Date
Date
Issued--------------------------------------------------------
Date
THE COMMONWEALTH OF MASSACHUSETTS
BOARD OF HEALTH
.......................................... OF .....................................................................................
Tntifiratt of TI-Impliatta
THIS IS TO CERTIFY, That the Individual Sewage Disposal System constructed or Repaired
by ---------------------
Installer
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has been installed in accordance with the provisions of TITLE 5 of The State Sanitary Code as described in 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................................................................................ Inspector ------------------------------------------------------------------------------------