HomeMy WebLinkAboutApp-Permit-ComplianceNo.. l 0 (_`c__9... Fies......j
THE COMMONWEALTH OF MASSACHUSETTS
BOARD OF HEALTH
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Appliratiun for Dispooul Works Tonsirnrtion rrrntit
Application is hereby made for a Permit to Construct
System at: ,-�-
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tfo - xAddress -
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Installer
or Repair (t/) an Individual Sewage Disposal
.........---•----------.............................•---•-•-•---•_._........•-•--.._...........
or Lot No.
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, - A dress,
Address
Type of Building Size Lot ............................ Sq. feet
Dwelling — Nd. of Bedrooms ........... G.! :.....ry.......................Expansion Attic ( ) Garbage Grinder ( )
Other — Type of Building uCy__ No. of persons....L) .................... Showers ( ) — Cafeteria ( )
Otherfixtures.-------•...............................................---..............-----........---•------------------...---------•--•---•--•---...---------••-•
Design Flow ......_..5 z............................gallons per person per �ay. Total dais flow ............ 21-0 ................... gallons.
Septic Tank — Liquid'capacity-Length. .,. ...... Width-.'LIL .......... Diameter ................ De)th.. ---........
Disposal Trench — No. ------- R------------ Width --- 1�.-0........... Total Length ..... ZO.--..... Total leaching area....��._!: __.._sit.
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 ........................
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Descriptionof Soil ..........................................................................................
.............................................................................................................. ----------------.....-•-------•-------------------........................------...---...
Nature of Repairs or Alterations — Ans er when applicable ... Oala
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Agreement: (�u.�_ ' Qom..
The undersigned agrees to install the aforedescribed Individual Sewage Disposal System in accordance with
the provisions of TITIZ 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.. -•-n "-1 `a .?
Die
Application Approved BY--- --•- . . .. .... .....••---•-•---------...._........-••------------........ %. ?IQ ........
�Date
Application Disapproved for the following rey ons: ..... yl..............................................................................................
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No ............... S --........ Issued------- `��- c�.- Date......
Date
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THE COMMONWEALTH OF MASSACHUSETTS
BOARD OF HEALTH
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Trrnfiratp of Toutplianrr -
THIS IS TO CERTIFY, Thahe individual SewagS Dispoal System constructed ( ) or Repaired
----.............. -.................................................
> Installer
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has been installed ir;cordance with the provisions of TITLE 5 of The State Sanitary Code ffa�1 described, in the
application for Disposal Works Construction Permit No ------ -_ �._) �.__.-____-_ dated--..---_ L_ __�J -T. �-- ---------
THE ISSUANCE OF THIS CERTIFICATE SHALL NOT BE CONSTRUED S A GiJARANTEE THAT,THE:
SYSTEM 1NIL FUt4CTION SATISFACTORY.