HomeMy WebLinkAboutApp-Permit-Compliance I� : _
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TME COMMONWEALTN OF MASSACHUSETTS
BOARD OF HEALTH
I. � _........_.._._._...------.__._---OF.............._.....................___.:............----'----......_..............
,�p�rlutttinn fur �i,��ru,sttl �,ark,� (��ns�ur#iun �e�mi#
Application is hereby made for a Permit to Construct ( ) or Repau (1CJ an Individual Sewage Disposal
System at:
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tiov Ad r�e.ss/n/ �� /J /J .......""'"""""'"'""'"""'"'""""'"""'_or Lot No.
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� i/ _ Address
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� nstaller Address
� Type of Building Size Lot............................Sq. fect
a Dwelling—No. of Bedrooms............................................Expansion Attic ( ) Garbage Grinder ( )
Other—T e of Buildin � ' ( )
P. YP g ---------------....---- No. of persons------------------------ Jhowers ( ) — Cafetena
a' Other fixtures ...--....---------- - -
� -----------------------------------�---��----� -----------------------......-----------------------
W Design Flow------------.---------------------------gallons per person per day. Total daily flow..-.--------------------------------.---gallons.
WSeptic Tank—Liquid capacity............gallons Length__._._.__...__ Width________________ Diameter...._.__.___.._. Depth_..........___
�, Disposaf Trench—:Vo- -------------------- Width--_-----..----_.._ Total Length-----..----_.------ Total leaching area.-------------------sq. ft.
� Seepage Pit No.------_....-------- Diameter----_--_--.----... Depth Uelow inlet------------_-•---- Total leaching azea._------_---•---sq. ft.
z Other Distribution box ( ) Dosing tank ( )
aPercolation Test Results Performed by..---------------------------------------------------------.---.. Date--------------------------------
,.a Test Pit \'o. 1.............._minutes per inch Depth of Test Pit_.........__.._. Depth to ground water_..._.....__..__.__._.
W Test Pit \o. 2................minutesper inch Depth of Test Pit__.................. Depth to ground water...___...__._._...___._.
R'' .--.............._....--....------------��---------------•-•------------------------_.._----.._...---------•---••-----------------------------
� Description of Soil-----------------------------------�------------------------------------------------------------------------------------------------------------------
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V Nature of Repairs o; Alterations—Answer when applicable.-G��.___.....��."-" --�����4.9r�ll'.'.`-'-------------
------------------------------------ ----------.......--------------....---------------------- --- -- - ------�--------- -- - -------------------.......-------
Agreement:
The undersigned agrees to install the aforedescribed Individual Sewage Disposal System in acwrdance with '
the provisions of:i'::..:, 5 ot the State Sanitary Code—The undersigned furthet agrees not to place the system in
operation untIl a Certiricate oi Compliance has been issued by the board of health.
Signed--- --...------------------------------...---------------.....-------------•- ---------��.C--�---
Application Approved By---�-�--------- --------------------------------....---------------...--•---- • �-- ----- �`�'---
'_""'_ � Dat� _....
Da
Application Disapproved for the foldowing reaso •
------------------------------------------ ---...------•------------------•-----------•__ -----•----•-------------------------... -------�-------...-----------•-----------
Date
PermitNo..-------------•------------------....---------__ Issue�........---•------_..-------....__......._..._._
�
TNE COMMONWEALTH OF MASSACHUSETTS ��C ^ �6C � �
BOARD OF HEALTH r� �
.......................... �......OF.......y. ...........................................................................
(�rxtifu�fr uf f�um�littnr� '
THIS IS TO CE IF ,-That the Individual Sewage Disposal System constructed ( ) or Repaired (�O
by------------•------��� --- I
_---- --....--••------------•• -------------------------------------------------------•-------------.....------_....----
p �/ mq�{�v c- ------------------------------y----- �,
at-------------0........--- - -- -- ----- - ..G!.------------Gt1'----�-- -------�-------------•-•------------- i
has been installed in acwrdance with the provisions of TI1 LB C/� of T e St te Sanitar Code a descri in the �
application for Disposal Works Construction Permit No.___..�.�..Q..__-��.� . dated_...._.._ .. �� �� i
� I
- -----------------
THE ISSOJANCE OP THIS CERTIPIC/!TE SHALL NOT BE CONSTRUED 5 A GUA ANTE THAT TFIE '
SYSTEM W�L FU/NCTION SATISFACTORT. p
DATE---..�_�-=�e{--�---------------�---.......-•--------.......__ Inspector-l�=.-------- -------� --------------...--•----------..__...._...-------- 'I
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