HomeMy WebLinkAboutApp-Permit-Compliance~-~-- .
THE COMMONWEALTH OF MASSACHUSETTS
BOARD OF HEALTH
.......... OF .............. X�� ...........................................
Application is hereby made for a Permit to Construct or Repair ( V� �an Individual Sewage Disposal
System at:
...... 4 .... 9. �, ......... .. .....
or Lot N
Type of Building Size Lot .. Sq. feet
Dwelling —No. of Bnlrouoox---------------------' Expansion Attic ( )Garbage Grinder ( )
Other—Type of Building ............................ No. ufperaooa----_-------_ Sho,vcca ( ) -- Cafeteria ( )
Otherfixtures ---_-------_---__________________________________________________________
Deoigo Flovv--------------.-------galloouperyer000yecduy. Total daily flow -------------------------------------------- gallons.
Septic Tank—Liquid capacity ............ gallons Length_ .............
Width ................ Diameter ................ Depth ................
Disposal Trench --YJu.................... Width .................... Total Length .................... Total leaching area .................... sq. ft.
Seepage Pd No ............. '....... [)iazootoc-----.---. Depth below inlet---------- Total leaching area .................. sq. ft.
Other Distribution box ( ) Dosing tank ( )
Percolation Test Results Performed bv.......................................................................... Date ........................................
Test Pit No. l................ minztespezinc6 Depth ofTest Pit .................... Depth togroundwater ........................
Description of
i'&Airs or Alterations —Answer when applicabl 4W .. 4 4 -
Agreement:
The undersigned agrees to install the aforedescr
the provisions of T IT LEj 5 of the State Sanitary Code
operation until a Certificate of Compliance has been
Application Disapproved for the following reasons . .........
1-1
Sewage System in accordance with
%dll,, reees to place the system in
.................... ..............
Date
Date
Date
THE COMMONWEALTH oFMASSACHUSETTS
(9rdifien Of (9 fiattrr,
That t 91 e'Indix�id al Sewage sal S ste, constructed
) or Repaired /k~Y�
has been installed in accordance with the p isions of TITLE 5 of The State Sanitary Code as described in the
THE ISSUANCE OF THIS CERTI /ICATE SHALL NOT BE CONSTRUED AS A GUARANTEE THAT THE
SYSTEM WILL FUNCTION SATISFACTORY.
P