HomeMy WebLinkAboutApp-Permit-ComplianceTHE COMMONWEALTH OF MASSACHUSETTS
BOARD OF HEALTH
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Appfiration for Disposal Works Tonstrudion Errant
Application is qereby ma0e for a Permit to Construct ( Gr0f'Repair ( ) an Individual Sewage Disposal
System at: H'mrea g
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��L atio A dress G rc�w� CJ I" F' or Lot No.
..-��..... ��r ..��.,.._...... .. ?Z s:?_&;A�-
Owner Address
Installer Address r ��
Type of Building Size Lot_ __��....=_... Sq. feet
Dwelling —No. of Bedrooms ......... ............................. Expansion Attic ( j Garbage Grinder ( )
Other — Type of Building ............................ No. of persons ............................ Showers ( ) — Cafeteria ( )
Otherfixtures ------------------------------------------------------.........--------------..........--------------------...------------------------....------------
Design Flow .............. ......................gallons per person per day. Total daily flow .......... .5.3.0 .................... gallons.
Septic Tank — Liquid capacity/__ __ _ }_ }allons Length ... j6__ Width..!........ Diameter ................ Depth ... -._.
Disposal Trench — No_ ____________________ Width ..... Total Length ------------------- . Total leaching area ................... sq. ft.
Seepage Pit No....., ....._._.. Dia eter__ A ......... Depth below inlet___41:�....... Total leaching area__-5S—C2_.sq. ft.
Other Distribution box Dosing tank ( )
Percolation Test Results Performed by..21..:_4AedV1_n..1........................... Date ... _1. Ae'Klpl_...........
Test Pit No. I ..... :4;ez_minutes per inch Depth of Test Pit_ Z . Depth to ground water.... 9..,�....__...
Test Pit No. 2................minutes per inch Depth of Test Pit .................... Depth to ground water ........................
.................... :..... ..........................................•-----.---.........--------.. _......._._._....--._....`.....
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Description of Soil _...Q
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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 TITLE 5 of the State Sanitary— e undersigned further agrees not to place the system in
operation until a Certificate of Complianc !�s_rb issued e� boat/ f health.
Application Approved By
Application Disapproved for the
Permit No......... a,,, — �..s..._._...... Issued ............. '� '
...._ ._ Date au •_•_"
THE COMMONWEALTH OF MASSACHUSETTS
BOARD OF HEALTH
V. ............OF... %`•:r?r�?!,7...................................
Trr#if iratr of Tontpliatta
THIS IS TO CERTIFY, That the Individual Sewage Disposal System constructed ( or Repaired ( )
r�"`
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 CONSTRUE® ASA GUARANTEE THAT THE
SYSTEM WILL .FUNCTION SATISFACTORY.
DATE.--•-••------............................................................ Inspector----------- --.......................-.............................................