HomeMy WebLinkAboutApp-Permit-ComplianceNo ..... ��
Fxf�...
THE COMMONWEALTH OF MASSACHUSETTS
BOARD OF HEALTH
��.......OF.---....�wbek_
Appliration for Dhgpwi al Marks (faanitrnrthin thrutit
Application is hereby made fora ermit to Construct ( ) or Repair ( �n' Individual Sewage Disposal
System at
Lo i
.Location - Address /./ or Lot_
O .7 Add ess
... .- ....----,=........-- -----
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. 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 ........................
Description of Soil............
-------------------------------------------------•-----•--•-------------•-----------------••-•••--------------- - -- - -
Nature ofpa�i -s or terat' ns — Ans when applicable ..__! _.__ _....1�% z_ _� ..�......
�l
Agreement:
The undersigned agrees to install the aforedescribed n ividual-Sewage Disposal System in accordance with
the provisions of TITTLE 5 of the State Sanitary Code T epnd s' -finer uagree of to place the system in
operation until a Certificate of Compliance has been ' ue t e ar he
Application Approved By
Application Disapproved for the f ollme g reasons:.....
--------------------------------------- ......................................................
PermitNo.....�..........................................
Date
"' ..... .
Date
----------------------------------------------------------------------•----
Date
Issued ------------- =1 ---------
Date
THE COMMONWEALTH OF MASSACHUSETTS
BOARD F HEA
...... �h.....(/.............. OF....
...1
) &riifirafae ,af (EaantlrltFanrr
TH fIS,,TO CERT o at e I ual ,,e`'z e Disposal System constructed ( ) or Repaired
........... .............. a .............................................................. Irkdt2er
has been installe i accordance with the provisions of TIT 5 of The State Sanitary Code as described in the
a lication for osal Works Construction Permit No o------ ____________ �
PP P dated-----'
THE ISSUANCE OF THIS CERTIFICATE SHALL NOT BE CONSTRUED AS A GUARANTEE THAT THE
SYSTEM WILL UN TON SATISFACTORY.
!�
DATE... , _4- 2------------------------------------------ Inspector ------------------------------------------------------------------------------------