HomeMy WebLinkAboutApp-Permit-ComplianceNo.. .v._J / Fm% ..............................
THE COMMONWEALTH OF MASSACHUSETTS
''BO 11RD OF HEALTH
.............. .0 ...... OF ............ ,...................................................•--
Appliration for 0hip.asal Works Tonstrurtiun thratit
Application is hereby made for a Perm' to Construct ( ) or Repair ,K) an Individual Sewage Disposal
System at:
.......... ............................ - ...... ....------------:_ ........---------....
yooc-a"tion . Address -- •------------------••.•---_. or • Lot No.
................F ------..a i f . �..- ......... ..................... r ......................................................
..... ... ._....
O ner Address
.................... ............ . ....C_ --
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 .......................................................................... Date ----------------------------------------
Test Pit No. I................minutes per inch Depth of Test Pit.................... Depth to ground water ........................
Test Pit No. 2................minutes per inch Depth of Test Pit.................... Depth to ground water ........................
Description of Soil ------------------------------------------
......................................................... -------------------------- ..............................
Nature of Repairs or Alterations —Answer when applicable...`.
- 7)
Agreement:
The undersigned agrees to install the aforedescribed Individual Sewage Disposal System in accordance with
the provisions of TIT12 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...................................................................................... --_-----_---------...._....
p D to
Application Approved By--------------- l t e ----- r--- ��---------------------- - Z Date 7
Date -
Application Disapproved for the following reasons:...
Permit N
Date
Issued--------------------------------------------------------
Date
THE COMMONWEALTH OF MASSACHUSETTS
OARD OF HEALTH
Trrt fi of anrr
THIS IJ&j TO CERTIFY I That the Individual Sewage Disposal System constructed ( ) or Repaired (
by/..l-----------•--•-------------------------------------------------- ---------------------------------------------
Install-,-7,—at
nstaller I
1
has been installed in accordance with the provisions of T 5 The State Sanitary Code as de-cribed in tl
application for Disposal Works Construction Permit No._ __. .. ... 3.-/ dated ----- ; _'
THE ISSUANCE OF THIS CERTIFICATE SH L NOT BE CONSTRUED AS A GUARANTEE THAT THE
SYSTEM WILL FUNCTION SATISFACTORY.
DATE................................................................................ Inspector.