HomeMy WebLinkAboutApp-Permit-ComplianceNo.2.:.�{ i.... FEs...r D7.)
THE COMMONWEALTH OF MASSACHUSETTS
BOARD OF HEALTH
..................l .!1✓..._. ...... OF .......... l .f .v ................................
Appliration for Dhiposdi Works Tonstrurtion f amit
Application is hereby made for a Permit to Construct
System at. -
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.... __........................................................
'L/o/p4Add
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car
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Installer
Type of Building
) or Repair ( ) an Individual Sewage Disposal
----� s I... .................
. - ........._
led
�!................................................... -
Address
......................................
Address
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. 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 ..............................................................
............................•--------••--•--------------.....-------------------•----.........
-------•-•-------------•--•-•-•--•---------••-•••---•-•-•--------•-----•-------••-•-------------------••-•-----•-• ti
Nature of Repairs or Alter ga§..:—_Answer when applicable __-_-____ -�-
-•-----•.................
Agreement
The undersigned agrees to install the aforedescribed Individual Sewage Disposal System in accordance with
the provisions of TITIE� 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 he board health.
Signed......... ........................ ..............
Application Approved By ..........0-71,11..............................
Application Disapproved for the following reasons: ..............
PermitNo.------------------------------------------
����� Date--------------
lDaate
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�i(JVL� J� d��Date
Issued_----A--------�--------------------•-----
THE COMMONWEALTH OF MASSACHUSETTS
BOARD OF HEALTH
11 '�
g a�rr: '. .................OF...:.. ...�e%.f . ' .le'.r:.. ...............................
�rrtifira..of Toutplittnrr
THIS IS TO CERTIFY,., That the IqdividualrSewa e "Disposal System constructed ( ) or Repaired ( 19)
by............... :::r ° t:.. ....... /:_'fit------ ................................. .....................................................I
Installer
at-•------
has been installed in accordance with the provisions of 'ITL 5f The State Sanitary Co a asJclescribed in the
application for Disposal Works Construction Permit No._;S& S0_j-.._._••-•••.-_---•- da.tecL-.��,�._ �.......................
THE ISSUANCE OF THIS CERTIFICATE SHALL NOT EEC _ STRUE® AS A GUARANTEE THAT THE
SYSTEM , WILL UNCTION SATISFACTORY. --,
DATE..
............................. Inspector;__: ' ' B I Z ....................