HomeMy WebLinkAboutApp-Permit-ComplianceNo.. (..f.._... ...
<< THE COMMONWEALTH OF MASSACHUSETTS
_ BOARD OF HEALTH
...............OF...... s��1%C.:.:._..:..v:...............................................
Appliration for Kliopoottl Worko Tiam5trnr#inn rrmit
Application is hereby made for a Permit to Construct ( 61"'or Repair ( ) an Individual Sewage Disposal
4P 3 " System at:
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Laeation - Address
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or, Lot No.
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Address
Type of Building ':5
Dwelling — No. of Bedrooms.. .............?.........................Expansion Attic
Other—Type of Building ............................ No, of persons............................
Address
Size Lot Sq. feet
Garbage Grinder ( )
Showers ( ) — Cafeteria ( )
Otherfixtures - ------------------------------------------------..................---.............------
Design Flow.......... . . ........................gallons per person�per day. Total dai1Y flow............ .................gallons.
Septic Tank—Liquid capacityZ"eZ2gallons Length �'.. ... Width.. rte✓ .
.._ .. Diameter ................ Depth.., ...e.
Disposal Trench—No... .................. Width..f..... Total Length.................... Total leaching area .................... sq. ft.
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Seepage Pit No ...... /_....._.. Diainetert'.'G:?.`��._r Depth below mlet.�t..6".KJ...... Total leaching area..6.:`✓.(r%sq. ft.
Other Distribution box ( Dosing tank ( ) s�
Percolation Test Results Performed by.. ...e�- - - - — — --- -- -- �------- ---------........ Date ... .:��������.
Test Pit No. L...'�"�...d�c:..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........................
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 S 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.
......... a ............ .........................
Date
Application Approved By.......... ........ ........ _ .........
....................
Date
Application Disapproved for the following reasons: .................................. ............................... ............. ..............
.................................... .......... ----•- ................................ .................. ....... ......._.•--....................................
Date
PermitNo ......................................................... Issued .......................................................
Date
THE COMMONWEALTH OF MASSACHUSETTS
BOARD
/.�02 F HEALTH
.....s`••�..G�Cr2J.......... OF...,o`../.":..........:.....................................................
T.rrtifiraU of Tomptittnrr
THIS IS T0'C1WIFY, That
Disposal System constructed (t:4 -Sr Repaired ( )
—1> .... ................ r .. Installer
at....... ..i'J..�� �.....�r�...�t°...... °s�a �..re�l..f 7. .G�.......C7t �!?.....f
has been installed in accordance with the provisions of TITLW j,of The State Sanitary Code as described in the
application for Disposal Works Construction Permit No..�//% .................. Betted._."`.. m 5y/...... ..
THE ISSUANCE OF THIS CERTIFICATE SHALL NOT BE CONSTRUED AS A UARANTEE THAT THE
SYSTEM WILL FSIN TIO NSATISFACTORY. /,�
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DATE. ---.::......................-•-------•------.. Inspector....-------------------•-------- --....