HomeMy WebLinkAboutApp-Permit-ComplianceNo..�1-..... �.�
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THE COMMONWEALTH OF MASSACHUSETTS
BOARD OF HEALTH
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Appliration for Uioirogal Wark.5 Tonotrur#iott rermit
Application is hereby made for a Permit to Construct ( ) or Repair ('') an Individual Sewage Disposal
System at: r L_trvtA.. y q,
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e^may Lo anon -Address or Lot No.
...... ........ ..`....... ..C.i t./�. ... ..........�%.�',,rte ............-.......... .........
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` �p_wncr, `` - _ Address
........4.....�}�....t............. '---`='•.d..4:aR..�:T. .................... ............ger.... ...... .2;.tM.V.C...LT.i:..... K.Y2.?.:H:...........
....
Installer Address
Type of Building Size Lot ............................ Sq. feet
Dwelling—No. of Bedrooms..........3.............................Expansion Attic ( ) Garbage Grinder ( )
Other—Type of Building ............................ No. of persons............................ Showers ( ) — Cafeteria ( )
Otherfixtures .... ....................... ___ ................. --.................................................................
Design Flow ......... T.......................gallons per person per day. Total d}ail7 flow............. Z.3.�...............gallons.
Septic Tank J Liquid capacity../S !?gallon Length --- Width ... Z.�..... Diameter ................ Depth................
Disposal Trench i) No. ..... Z ....... .... Width.............. Total Length.....(G,...... Total leaching area...,. ............... sq. ft.
Seepage Pit No...... ............... Diameter.................... Depth below inlet.................... Total leaching area .................. sq. ft.
Other Distribution box ( 4-) --- 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
of Repairs or Alterations — Answer when
Agreement: . I
The undersigned agrees to install the aforedescribed Tndividual Sewage Disposal System in accordance with
the provisions of TITIT: 5 of the State Sanitary Code — The undersigned further agrees not to place the system in
operation until a Certificate of Compliant •ued by the bo of teal
Signed..... : �,� . _ .. .�. 1.1
... ...... r....�.
Application Approved By------------ .... r. ............................ .............. ............. ........... /r��{ �•.�'
/ Date
!Application Disapproved for the fo 16 in, reason.r....................................................... .-------......------- -......------------.
Permit No ....... U..." . 2
THE COMMONWEALTH OF MASSACHUSETTS
BOARD OF HEALTH
........... - _.. OF..... '.t. ii. r"�'i of y: 4!.......i ................................
(gatifirate of Tontplittnre
THIS IS TO CERTIFY,,That the Individual Sewage Disposal System constructed ( ) or Repaired
...
' t
has been installed in accordance with the provisions of T j,m , 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 CONSTRUED AS A GUARANTEE THAT THE
SYSTEM WILL FUNCTION SATISFACTORY.
y : - DATE.. "