HomeMy WebLinkAboutApp-Permit-ComplianceIr*
No..��- --
THE COMMONWEALTH OF MASSACHUSETTS
BOARD OF HEALTH
- ............._.........................OF ......................................
..............
, ppliration for lliipoii al Works Tonitrnrtion Prrmit
Application is h ade for a Permit to Construct ( ) or Repair (.i_an Individual Sewage Disposal
System at:
................ - - - -1 .............. . lam.... Ce p '- ...........-• T = = L--- ---- a4 f' lral�
ocation Addf or Lot No.
..._.__ ..-....................................
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wn r —Address
Installer Address
Type of Building Size Lot____________________________ Sq. feet
Dwelling — No. of Bedrooms ............................................ Expansion Attic ( ) Garbage Grinder ( )
Other — Type of Building ____________________________ No. of persons ............................ Showers ( ) — Cafeteria ( )
Other fixtures
......................... .............................................................................................................................
Design Flow ............................................ 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. L_______________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 ........................
Description of Soil_________
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Nature of Re, airs �rrAlt erations —�swer when applicable._7-------- _ �QCt t _______Z�5
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Agreement:
The undersigned agrees to install the aforedescribed Individual Sewage Disposal System in accordance with
the provisions of TTT y g g p y
5 of the State Sanitary Code —The undersigned further agrees not to lace the system in
operation until a Certificate of Compliance hAdsons:
ed by the board of health.
gne-----•-------•--•--•--•--.......__.......•-•'--•-----•---•------•---------••---•-•---•------------•
ioApplication Approved By. -----• ----- -•---•----------•-----•-•--------------• gl at
Application Disapproved for the following r ---
Permit No.
THIS
-------------------
Date
Issued-----------------------•--•--•---•-•---"-•---------_..
Date
THE COMMONWEALTH OF MASSACHUSETTS
BOARD OF HEALTH
...__. .............. O F....''���..............................................-._-..
Trrtifiratr of Tomplianrr
RTjIFX� Tt'I[e Individual Sewage Disposal System constructed ( ) or Repaired ( )
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` .................... Installer
�,-% �� �•2 cam, r�� . _,-C �.c...-.�_.-� � -cJ.
has been installed in accordance with the provisions of TITLB j of The Sta;�Sanitary Code_ as slescribepi in the
application for Disposal Works Construction Permit No.____�__-..... dated ----------- --- �
THE ISSUANCE OF THIS CERTIFICATE SHALL NOT BE COSI UE® AS A GUARANTEE THAT E
SYSTEM WILL FU TION ATISFACTORY. � ,/ = �
DATE......
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