HomeMy WebLinkAboutApp-Permit-Compliance.� N`I., Fuse•...............
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THE COMMONWEALTH OF MASSACHUSETTS
BOARD O HEALTH
.......... OF .......... ..I...........................................................................
Appliratio t for Btopooa Works Tonotrurtton ermit
Application is hereby made for a Permit to Construct ( or Repair ( ) an Individual Sewage Disposal
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at:
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40
....._....._ ................................
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Installer
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C_ :al._ll...f..l...t11.!_.rC.............................
es�sy�
Address �S
Type of Building Size Lot ------------------- Sq. feet
Dwelling —No. of Bedrooms............................................Expansion Attic ( ) Garbage Grinder ( )
Other — Type of Building ----_-------------- ------ No. of persons-___._--------------_..-__ Showers ( ) — Cafeteria ( )
Otherfixtures-----------------------------------------------------....------------------------------------------
Design Flow ........... 5 �........................gallons per person per day. Total daily flow ..................... ................. gallons.
Septic Tank — Liquid' capacity/-V.a.gallons Length ................ Width.. ....... Diameter._-_____-__-.-_- Depth��_;��
Disposal Trench — No. .. .............. Width-�............ Total Length.___' .......Total leaching
Seepage Pit No ..................... Diameter .................... Depth below inlet=................... Total leaching area .................. sq. ft.
Other Distribution box (.) Dosing tank
Percolation Test Results Performed by .... ..�'-s�).c-t- ______________ Date ....
Test Pit No. 1 a!-7�ninutes per inch Depth of Test PitZ.J�- y-. Depth to ground
Test Pit No. 2................minutes per inch Depth of Test Pit ... ................. Depth to ground water ........................
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Descri tion of Soil... �? ..... r 7 �z _.._... __ '�
P �--------------------------------------------------------- -•------------------
----•-•-•-------------•-••-------•----------•••-•----••---------........-----.........------•-------------••----•--•--••---••-------•-----------......_.....------•-----------------------....----------
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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 TITIL 5 of the State Sanitary Code — The undersigned further agrees not to place the system in
operation until a Certificate of Compliance has been issugd by the, board of health.
Application Approved By
Application Disapproved for the f ollowinfi reasons:
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.................................................r..------•-----•••-•-......--•-•-----t"--------------.........-----•........................... .---.................... ------...to------
Permit No ......... -"--�-•--- jY y---• ........................ Issued .--.---- ---- �.-I*-L IF --•---
Date
THE COMMONWEALTH OF MASSACHUSETTS
BOARD OF HEALTH
........�..t.�..Z(1X................OF.......�. ..��..J...`:.!.�` Da—Lb....................
(Irftfira of f-Omplidxtrr
THIS IS TO CERTIFY, That the Indivi al ySe Vge Disposal System constructed or Repaired
bY---•---------------- ---------------------------------------------------------
----------- Installer
at........................................... ------------------------=� ��-��-�G �i - --•- -� - ="......-------------------------•---•------
has been installed in accordance with the provisions of TIT o�jj�jj State SanitaryCLRAN
de as de c '�ed in the
application for Disposal Works Construction Permit No .............................. _.......�_.I.......... dated ... . ................
THE ISSUANCE OF THIS CERTIFICATE SHALT. NOT BE CONSTRUE® AS A EE THAT THE
SYSTEM WILL FUNCTIOISV SATISFACTORY.
DATE...................... .. ................................... Inspector..----- - y- "'