HomeMy WebLinkAboutApp-Permit-Compliance(
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THE COMMONWEALTH OF MASSACHUSETTS
BOARD OF HEALTH
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� ,��r}�lirtt#iun fur �i��nrsttl �urk,� (nun,�#rxu#inrn �rrmi#
i Application is hereby made for a Permit to Construct (X) or Repair ( ) an Individuai Sewage Disposal
System at:
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� . . ._— '""' ation.Ad re s . ' ' ' '"'""_"'......""""""' _""'....""""'""'_"""""'""
/� �,� or Lot No. �/
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W Owner Address
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Ivstaller '""""'""'""""'""'"""'"".......""'"'.Address '"...""'_.`,.."_'.'...........5(�. fCEK
� Type of Building / Size Lot_..Z_� '�.!.4?.._..
a Dwelling—No. of Bedrooms.__........"f"...........................Expansion Attic ( ) Garbage Grinder ( )
aOther—Type of Bvildivg _..................._.._.. No. of persons........__._.._............. Showers ( ) — Cafeteria ( )
� Other fixtures ----- ......... - --------------- --------------- - - - --_.----------------------•----------------•-----------
W Design Flow...................._----.-----_•--------.gallons per person per day. Total daily flow-__----..�.Y.[�Xn-_-_--------------gallons.
, 0.S Septic Tank—Liquid�capacity.�442Q.__gallons Length................ Width_............... Diameter.._.........._. Depth....._.....__..
W Disposal Trench—:Vo. .................... Width.............__..... Total Length_____........_..__.. Total leaching area........___.___...__sq. ft.
x _
� Seepage Pit :Vo._._....�........... Diameter_.__1z.b.'_. Depth below inlet_..._��......... Total leachingarea.�l.s$t.3..sq. ft.
z Other Distribution box (�) Dosin�nk ( ) ,
a Percolation Test Results Performed by._.Fi�c�:!..4eY.s,�.._�Y�.✓.!k--.. .Pr..�_._ Date.._.`.�..._ ._ 4'p.IR.`.I�..
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M Test Pit Vo. 1�z.._..minutes per inch Depth of Test Pit____�.�.�......_. Depth to ground water__�7Y1!e..._.
, W Test Pit No. 2...__.____..._minutes per inch Depth of Test Pit.................... Depth to ground water....__...........1._:..
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Description of Soil...._v- -3`�+�---'---Sa�nd,`-�--loa,v�._�_'�42p6t�.i i----------------- �-----.......- -----------------------------
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x �---....... -- i'ro-----1��'� `--M�i.�v»�._S�ca.:nd-----------� --�� ------- ---------------------------------------��--------..:..._.
V Nature of Repairs o: Alterations—Answer when applicable-----__--_.-_.------_.-------._--_.------_-_-.-_------------------___-----_-----.
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Agreement:
The undersigned agrees to install the aforedescribed Individual Sewage Disposal System in accordance with
the provis:mis o1:i i'i..; 5 oi 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---------........................--------------�------------------------ -------------...----------
Date
ApplicationApproved By--------�---------- ----�---------------------------•--------�------------------•-------- -------------------�----•--------
Date
Applieation Disapproved for the foldouring reasons:--._----------....----------------------.-----------.----------------------------------------
-------------------------------------------�------ �-------------------------------------------- ---...-------------------�-------...- --D�-----------...--- -----------..
Permit No.t�--`�- ---��-�----- ---------`-�—��� Issucd--��•-�-i-9.�7��"""""'"'"".Date "'"""
THE COMMONWEALTH OF MASSACHUSETTS
BOARD OF HEALTH
........._�. ..W...Y.'1..._..........OF.............._u"l�!1Q.I!l.('!.`..
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�FI tt�t[FI ��iit}tIiFC1tIP
T�� IS TO�BRTIFY, That the Inciividual Sewage Disposal S�stem mnstructed ( or Repaired O
by.....,1�C]1=1-..-------1---�0.'-}-^-+-,•.-,�--�-y-r--------------•---------------�-----.......- -------------------._....------------------•------------•----------------•--------._
8�."��"../."""'_�.X7-e"''..._!41.!l.�.""""'"""""""""""""""Installu """"""""""""'""""_""""""""""""""'"'""""""""'""""""""""'..
has been installed in accordance with the provisions of TI i'I:' j�/o�f�he State Sanitary Cqde a described in the
application for Disposal \Vorks Construction Permif�o.._..`I�-.T�................... dateci_..��.I.�9--�7.�......._......_.____.....
THE ISSUANCE OF THIS CERTIFICATE SF9ALL NOT BE COPISTRUED AS A 6UARANTEE THAT TFIE
SYSTEtA W LL UNCTION SATISFACTORY.
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