HomeMy WebLinkAboutApp-Permit-ComplianceNo.- ---���=--2-- Fps ..............................
THE COMMONWEALTH OF MASSACHUSETTS
B AR® QF HEALT
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App iratilan for Dispaii allark fn
rrutit
Application is hereby made for a Permit to Construct ( or Repair ( ) an Individual Sewage Disposal
System at:
1 -
Locati Add s�, �j� or Lot No.
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wnef�j Address
Installer Address
Type of Building Size Lot ---------------------------- Sq. feet
Dwelling —No. of Bedrooms._=Z .................................Expansion Attic ( ) Garbage Grinder ( )
Other — Type of Building ............................ No. of persons ............................ Showers ( ) — Cafeteria ( )
Otherfixtures ---------------•---------•------------------------••--••-•-•----•-------•-----•-•-----•------•--•-------------................__............._•-------
Design Flow.................z'�:P------------ gallons per person per day. Total daily flow .......... 3.3.0 ........................ gallons.
Septic Tank — Liquid' capacity, 400_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. 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 ........................
Description of Soil...
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Nature of Repairs or Alterations — Answer when applicable................................................................................................
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Agreement:
The undersigned agrees to install the aforedescribed Individual Sewage Disposal System in accordance with
the provisions of TITLE, 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.
pne_-------------------------------- ..........Da.te..............
r Date
Application Approved B "a
PP PP Y.._.. pg
Health 0 1 1 Cer Date
Application Disapproved for the following reasons: ................................................................................................................
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Date
PermitNo ......................................................... Issued .......................................................
Date
THE COMMONWEALTH OF MASSACHUSETTS
OARD QF HEALTH ,f
.............�__!%r.OF.....:o�lG'..C./....%.(..................................
Trrtifir of f omplianrr
THIS IS TO CERTIFY, That the Individual Sewage Disposal System constructed ( or Repaired ( )
b............. C:.1 _2_._......_ ;c•' .i� �..r'Y-=� == -------••-•----------- -------•--•-----••-•----------•-----•-----•-••••-------•-----•-•-----•----•---•-----•---••--------------
Installer
at........... �a�---------------- �-------------•--...-------...-----------
has been installed in accordance with the provis' ns of TITLE ...5 of The State Sanitary Code as described 'n the
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application for Disposal Works Construction Permit No ...... X-4—____. _y .�„ydated ........ ;.�'p ................
THE ISSUANCE OF THIS CERTIFICATE SHALL NOT BE CONSTRUE® AS A GUARANTEE THAT THE
SYSTEM WILL FUNCTION SATISFACTORY.
DATE....................•---•--.._..----•--------••------•-•--•---------•---•-_..... Inspector