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HomeMy WebLinkAboutApp-Permit-Compliance`•J W U W x U No ....... ...... ... 114n Fims...I .`�©U... THE COMMONWEALTH OF MASSACHUSETTS BOARD OF HEALTH �� U-) &.) .--..O F..... A.;WPU� : MAP Co d Appliration for Diapwial Workii Tonstrnrtiun Prrmit Applicationissh reby made for a Permit to Construct System at: Cz�' ef, Location - Address or Repair (f✓) an Individual Sewage Disposal ....... */I.. or Lot No. ...................... —.......................................................................... ........•...._..................----•---.....--•--.i....----------...-•----•. Owner s 23 Aer'Ll Installer Address 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............................................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 ........................... ................... Test Pit No. I................minutes per inch Depth of Test Pit ........ Test Pit No. 2................minutes per inch Depth of Test Pit........ Descriptionof Soil .................................................................. ..... Date ........................................ __. Depth to ground water________________________ ... Depth to ground water ........................ Natur Repairs or Alterations—Anser when applicable..�'� Agreement: —A The undersigned agrees to install the aforedescribed ehdividual Sewage Disposal System in accordance with the provisions of TITiE 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 the board of health. Signed'... to ApplicationApproved By---•--. • . •. •---- -- ---- ......................................................... D to Application Disapproved for the f ollowi reasons:.. -------••••-----•-••..........-•--•---•--------------•--•-------•----------------------------••---••---••-•---------•-••------•---•--•------------------------------- ----------------------------- Date Date Permit No. ! ....................................... Issued /-------- --�----•----•------- Date THE COMMONWEALTH OF MASSACHUSETTS BOARD OF HEALTH X...................OF........ .. `. ..............._.............. Wrrtifirtt oaf fro plianrr / THIS IS TO CERTIFY, That the Individ 1 Sewage Disposal System constructed ( ) or Repaired (✓) by -•--.o:!.§ f ..... �::--�-', a ---------- ---•----------------.--.-.------•----•--••--------------------------------------------.--.---------- has been installed in ac rdance with the provisions of 1.1 ^ 5 of }�e tate Sanitary Codi. as escr' d in the application for Disposal Works Construction Permit No________ __ ___ ---. ..-.. dated_ -...___.!..z � 1 T U...._..... THE ISSUANCE OF THIS CERTIFICATE SHALL NOT.BE CONSTRUE �1 GUARANTEE THAT THE SYSTEM WILL FUN TI N ATISFACTORY. �,� DATF. I Z_ ( qD TncnPrfnr ,)f