HomeMy WebLinkAboutApp-Permit-ComplianceTHE COMMONWEALTH OF MASSACHUSETTS
BOA RD-/ OF HEALTH
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Appliration for Disposal Works Tonsftwtion Frruti#
Application is hereby made for a Permit to Construct ( ) or Repair (IV) an Individual Sewage Disposal
System`r .o�'o _-/� ..5 :.,z:pr�r. Q zc'.t........... ............ �T.�.J.��.�._. mi (.::.��... ..................--
Location - Address or Lot No.
............. . •- - ----- --- - -•--- - -----/�lr�,!_ �y �' f .........
t?.ff.......................... - .......... - .... .....
Owner Address l
..... ..&4o ../.1.�?r�!•s
Installer Address
Type of Building Size Lot ............................ Sq. feet
aDwelling —No. of Bedrooms....-.y..................................Expansion Attic ( ) Garbage Grinder ( )
p, Other — Type of Building ............................ No. of persons............................ Showers ( ) — Cafeteria ( )
CLI Other fixtures ---------------------------------------------------- • ---- -
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WDesign Flow............................................gallons per person per day. Total daily flow ............................................ gallons.
WSeptic Tank — Liquid' ca.pacity............gallons Length ---------------- Width ................ Diameter ---------------- Depth ................
x Disposal Trench — No ..................... Width .................... Total Length........---.-------- Total leaching area ................... sq. ft.
3 Seepage Pit No ..................... Diameter.................... Depth below inlet .................... Total leaching area ................. sq. ft.
Z 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........................
(i Test Pit No. 2................minutes per inch Depth of Test Pit.................... Depth to ground water........................
Description of Soil...... ----•-•-----------.
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Nature of Repairs or Alterations —Answer when applicable_-%!!E�. �.....$--e. O-Zis:................
Agreement:
The undersigned agrees to install the aforedescribed Individual Sewage Disposal System in accordance with
the provisions of TITLE, 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 oDie,-Llth.
Application Approved
Application Disapproved for the
PermitNo5.7:./eIt -------------------------------- ---..
THE COMMONWEALTH OF MASSACHUSETTS
14r 04e57
BOARD OF HEALTH
......OFFt 1 fit lJ.G.I L... .
Trr#ifxratr of T%utplf4urr
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L a
/ ate
�al,19�7 Date
HI •� IS TO CERTIFY, Tha�t, the Indiyidual Sewage Disposal System constructed ( ) or Repaired (K)
lt; i. --TLA'S:._..__...._
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Installer
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has
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has been installed in accordance with the provisions `of TITLE 5 of The State Sanitary Code as described in the
application for Disposal Works Construction Permit No. –.lin �Li'..................•. dated ._�?��- ✓�_ �� ...........
THE ISSUANCE OF THIS CERTIFICATE SHALL NOT BE CONSTRUED AS A,Ci .rRANTEE THAT THE
SYSTEM� ILL FUNCTION SATISFACTORY.~ 1
DAT f���.� �� c.� / T� -- Inspector.` r k?.__�fp�e �ils�.r�-------------------
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