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HomeMy WebLinkAboutApp-Permit-ComplianceI� a a N G*. O U W to U P(eVD 6` No.`(�-IGI...... 1� ©zZ t 2�5 �lJ`�... I ...... _ Fas. THE COMMONWEALTH OF MASSACHUSETTS BOARD OF HEALTH ...................... 'OF ............... .`.�....!.:.f'L.............. ................. Aunliration for Disnnsal Works (nonstrnrtion f rrmit Application is hereby made for a Permit to Construct System at: .... :.... Irl ..... ''j ..:............... Location -A css Owner .................... Installer Type of Building Dwelling — No Other — Type Other or Repair (V11*`an Individual Sewage Disposal .........f./..-'....�......�':::4�d. s'l..kA�.. o No, Aadre a �7 Address es: Size Lot ............................ Sq. feet . of Bedrooms............................................Expansion Attic ( ) Garbage Grinder ( ) of Building ............................ No. of persons............................ Showers ( ) — Cafeteria ( ) 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. I................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 Nature of Repairs or Alterations - Allswer when Agreement: s The undersigned agrees to install the aforedescribed individual Sewage Disposal System in accordance with the provisions of TITLi, 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 t board of h lth. �. so Application Approved Application Disapproved for the following reasons: Permit No.1E.—&1...................................... THE COMMONWEALTH OF MASSACHUSETTS BOARD OF HEALTH ..°..::.:.`.:...`.`....................OF.............f.`.,.�'`d.,.:.':@' �.`!..✓.................................. Trrrtifiratp C f faompliann THIS IS TO CERTIFY, That the Individual Sewage Disposal System constructed has been installed in accordance with the provisions of T,;,L7E a 5 of The State�Sanitav application for Disposal Works Construction Permit No...?.' ._. 2.i ...................... dated THE ISSUANCE OF THIS CERTIFICATE SHALL NOT BE CONSTRUED AS A SYSTEM WILL FUNCTION SATISFACTORY. DATE........................._......::......................................... Inspect( Date or Repaired ( w) in the THAT THE