HomeMy WebLinkAboutApp-Permit-ComplianceNo..�.7 Fps / :...............
THE COMMONWEALTH OF MASSACHUSETTS
BOARD OF HEALTH
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Appliratiaan for Dispaaaial Works Tomitrurtiaan ramit
Application is hereby de for a Permit to Construct ( ) or Repai``r// (>-I an nIn�fdividual Sewage Disposal
System at _. ----•- - ......... - o�.....j. �..- 1 1. .................
cation - Address or Lot No. '
H P ,O .
O r Address
Installer Address
Type of Building Size Lot ---------------------------- Sq. feet
Dwelling —No. of Bedrooms............................................Expansion Attic ( ) Garbage Grinder ( )
p, Other — Type of Building ............................ No. of persons ............................ Showers ( ) — Cafeteria ( )
a Other fixtures -------------------------------- .
W Design Flow............................................gallons per person per day. Total daily flow ............................................ gallons.
WSeptic Tank — Liquid capacity ............ gallons Length ................ Width ................ Diameter ................ Depth ................
x Disposal Trench — No ..................... Width .................... Total Length .................... Total leaching area .................... sq. ft.
Seepage Pit No ..................... Diameter .................... Depth below inlet .................... Total leaching area .................. sq. ft.
Z Other Distribution box ( ) Dosing tank ( )
Percolation Test Results Performed by ....................................
...............
------•--------------- Date ........................................
4
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 ........................
a'--------•--------------------------•----•------------------.._.................--•-••---•----•------ .........................................................
0 Description of Soil ........................................................................................................................................................................
x
w
x
U Nature of Repairs or Alterations —Answer when applicable.._.. � ___ _^ ___�fiN ..._..�Q®....... �-...
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Agreement: L—
The undersigned agrees to install the aforedescribed Individual Sewage Disposal System in accordance with
the provisions of TIT 1E 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...................................................................................... ................................
Date
ApplicationApproved By -------------------------------------------------------------------------------------------------- ........................................
Date
Application Disapproved for the following reasons- ------------------------------------•-------------------------•-----------------•-------------------------.-----
•--•------------------------------------------------•----........................._..........-----------•---------------•------------------•----------•--. ---------------------------------------------
Date
PermitNo ......................................................... Issued .......................................................
Date
THE COMMONWEALTH OF MASSACHUSETTS
BOARD OF HEALTH
................................ I......... OF .....................................................................................
(Intifiratr of Taamptiatt ae
THIS JS_'O URTIFV/That the Individual Sewage Disposal System constructed ( ) or Repaired (} .
4/IJ
has been instalXd in accordance with the provisions of TIT F5 of S te. Sanitary Code s descri d in the
application for Disposal Works Construction Permit No.___d_____ dated___ ... 1 ..._' -v-___.
THE ISSUANCE OF THIS CERTIFICATE SHALL NOT BE CONSTRUE® AS A G ARANT E THAT THE
SYSTEMA WILL FUNCTION SATISFACTORY.
DATE-------••--•-----------------------------------------------•-----•---------•--- Inspector