HomeMy WebLinkAboutApp-Permit-Compliance_ CV Ak
No. .1111/ . Fps............... ...............
THE COMMONWEALTH OF MASSACHUSETTS
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BOARD OF HEALTH
DGCi/t�........... OF.
.......
Appliration for Disposal Warks Tonstratr#ivat Vrrmit
Application is hereby made for a Permit to Construct ( Repair ( ) an Individual Sewage Disposal
7S stem at
. y... Z/ --- ...... r 4'.� -------------------------............. ?=...
Location - Address or Lot No.
�
...................... .......... .......................
.:....•-----•----.......--•--.........................................• -•---....----_........--------..........----
ownerj� Address ��... — �Gl e-•--------------------•---•------
Installer Address
Type of Building Size Lot ............................ Sq. feet
Dwelling —No. of Bedrooms ............ IJ ........................Expansion Attic ( ) Garbage Grinder ( )
Other — Type of Building ............................ No. of persons ............................ Showers ( ) — Cafeteria ( )
Otherfixtures-----•--------•------------------------•----••--------.-----------•---•-•--•-----------------•------ JJ ._.............._...........--
Design Flow ....... .3c ......................gallons per person per day. Total daily flow ........ ................. gallons.
Septic Tank — Liquid' capacity��Q0gallons 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 ----------------------------------------------------------------------------------------------------
•-----------------------------------------------•-------------------------------• _.. _....-------•------------•------------
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
the provisions of TI TIE 5 of the State Sanitary Code — The undersigned further -agrees not to place the system in
operation until a Certificate of Compliance has b en ' ed y e bo of wait tt'
Signe------ - --- - --�-- - - - - -y---- -{�-- �- •- ---� -- ---• ..........
Application Approved By---------------••--•----------..........---•-----...---•---•----....-----•-•-••-------•--••- t �7�---
�
Application Disapproved for the following reasons:..
Permit N
Issued ........................
Date
THE COMMONWEALTH OF MASSACHUSETTS
BOARD OF HEALTH
Date
...................... vF.r./:✓!/.u..r...../../.......................................
(9mitiritty of (1 outpliFaatrr
THIS IS TO CERTIFY, That the Individual Sewage Disposal S7stem constructed (/)or Repaired ( )
Installer
has been installed in accordance with the provisions of TITIF 5 of The State Sanitary Cods desc ibed in the
application for Disposal Works Construction Permit No. _ t•_�y���.................. dated___._, --_ --- 7?-----------
THE ISSUANCE OF THIS CERTIFICATE SHALL NOT BE CONSTRUED AS A GUARAN E THAT THE
SYSTEM WILL FUNCTION SATISFACTORY.
DATE -..---- I�------------------•-----------•---- Inspector---------------..... 0 -