HomeMy WebLinkAboutApp-Permit-ComplianceTHE COMMONWEALTH OF MASSACHUSETTS
BOARD OF HEALTH
OF........................................................................................••
ApplirFatiou for Disposal Warks Tons rartiott Prrutit
Application is hereby made for a Permit to Construct ( ) or Repair (,(� j an Individual Sewage Disposal
System at:
-- - X
......�� ,................. w ......... -.. '� .....•..
cation - Ad// cess or Lot No.
�• ------•------•--------- ..
....._.._
, ner Address
J`
Installer Address
Type of Building Size Lot ........................ 0 --- 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. 1................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 ........................
Descriptionof Soil------------------------------------------------------------------------------------------------------------------------
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Nature of Repairs or Alterations — Answer when applicable.....____... ____ .._�____ _____ ________________
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Agreement :
The undersigned agrees to install the aforedescribed Individual Sewage Disposal System in accordance with
therovisions of T i : L
p 5 or 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.
4 - --------------------
--------------------- -------•----
ed Date
OU iZ
Application Approved B...........---------------
�1CjS"1 Date
PP P -- °
Application Disapproved for the following reasons:---•----•---------------------------•----------------------------------------------- ---------------------'-----
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Date
PermitNo --------------------------------------------------------- Issued --------------------------------------------------------
Date
THE COMMONWEALTH OF MASSACHUSETTS
BOARD OF HEALTH
.......................................... OF .......... ..........................................................................
Tntifirtttr of Tompliaurr
THIS I$ -TO ERTIFY, That the Individual Sewage Disposal System constructed ( ) or Repaired/71
( )
by ---------------- - ' '- z y ........................... ----------------------
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�...gJ Pe!1r.?.. �Iler ----
at. ------ -=y'------ - - ..---------�------.
has been installed in accordance with the provisions of TITLE 5 of h ,,.tate Sanitary Code s des ib 4 in the
application for Disposal Works Construction Permit No ------- _�"' ���'--- dated ��?________________
THE ISSUANCE OF THIS CERTIFICATE SHALL NOT BE CONSTRUE® AS A G ARA TEE HAT THE
SYSTEM WILL FUNCTION SATISFACTORY.
DATE................................................................................ Inspector