HomeMy WebLinkAboutApp-Permit-ComplianceTHE COMMONWEALTH OF MASSACHUSETTS
BOARD OF HEALTH
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Appliration for ispas a Narks Tonstrnrtiun Prrmit
Application is hereb made for a Permit to Construct A') or Repair ( ) an Individual Sewage Disposal
System at:
...............= ---- - - - .fl...............
L - ti re
Owner
--------�'�r/f. �--------------------------------------
• / / Installer
Type of Building v
Dwelling — No. of Bedrooms ............................................ Expansion Attic
Other—Type of Building ............................ No. of persons ............................
Pod_- - ....MtgP_:�(6
r 3.o No.
.---------------------•---......................---• •-
Address
Address
Size Lot ............................ Sq. feet
Garbage Grinder ( )
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 ........................
Descriptionof Soil ..........................................................
.............................................................................................................................................. ................................
Nature of Repairs or Alterations — Answer when applicable......................................................................
Agreement:
The undersigned agrees to install the aforedescribed Individual Sewage Disposal System in accordance with
therovisions of TITI.;,..
p 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...................................................................................... ................................
.���t
Q-7
Application Approved BY-•----•------------•--•-----•---.'l/�. X-� •------ l�
�e
J �
Date
Application Disapproved for the following reasons:
Date
PermitNo ......................................................... Issued .......................................................
Date
THE COMMONWEALTH OF MASSACHUSETTS
BOARD OF HEALTH
................:..:.....'................OF........... is 1........................................................
Trr#ifiratr of Tout rfiatta
THS IS TOC RTIFY Thpt the Individual Sewage Disposal System constructed (,k(') or Repaired ( )
G'' Installer
at----------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------- ---_-----
has been installed in accordance with the provisions of TITL ,�_ j of The State Sanitary Code as described in the
application for Disposal Works Construction Permit N� �.. .....
.......... dated�:�_=".� �_ ..._, �__---__-__..
�_.
=:-
THE ISSUANCE OF THIS CERTIFICATE SHALL NOT BE CONSTRUED AS A GUARANTEE THAT THE
SYSTEM WILL FUNCTION SATIISFACTORY. �9
DATE.. { /T� -•? -•-- Inspector ...................................... .............................................