HomeMy WebLinkAboutApp-Permit-ComplianceF � y
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THE COMMONWEALTH OF MASSACHUSETTS
00 � -----,8 ARD ff HEALTH
hQree 11 �� /.6.a...._......OF........ .......4:1-- ---------------------------------------------------------
� Appliratiou for Dtapuull Works Tomuurvou Vamit
Application is hereby made for a Permit to Construct ( ) or Repair () an Individual Sewage Disposal
Systemat: �1........__.... ------. -----------------------------------•------
................ „....._
L cation - Address or Lot No.
................... -------------------- ---------------------------------------------------- --•-------------------------------•--•------
0- Address
a E .a.*I'................................ ...................... Address .........•...............................
Installer
Type of Building Size Lot ............................ Sq. feet
aDwelling — No. of Bedrooms --------------------------------- -.......... Expansion Attic ( ) Garbage Grinder ( )
pi Other — Type of Building ............................ No. of persons ------_-_-_------••--_..____ Showers ( ) — Cafeteria ( )
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 ----_-----------------------------------
aTest 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 ........................
----------------------------•-----•--------•------------•-••----------------._...-------•------••--....---•---------•---...-•-•--....---------•--------.---••
ODescription of Soil ..................................................................................................... ...............................................................
V----•------------------------------------------•---------------------•------------------•---------------------------------•---------------•--------------•--------------------------------------------
-------------------•-----------------•-•---•------•--------------------------•---------
V Nature of Repairs or Alterations —Answer when applicable._---_____,�.��_e-a- _.___. �_l._.___ _ __/__i-............................
..------•---------------------------------------------------------------------------•----------•------------... ---------------•----------------------•----------•--------------•••-- -----------------
Agreement :
The undersigned agrees to install the aforedescribed Individual Sewage Disposal System in accordance with
the provisions of TITL,:,. 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.
0�w _ Date
A
lication Approved B + �D a
PP PP y--••••--------
Heal th �fi ��� Date
Application Disapproved for the following reasons:--------•------------------•------------•---------•--- .........................................................
-•......................•-----------------•----••-----••---------••--•--------------••--....-•----------. -•----••••••-----------•-•--••----------••------•-•----••-•----------------•--••-••••--...-----
Date
PermitNo --------------------------------------------------------- Issued .......................................................
Date
THE COMMONWEALTH OF MASSACHUSETTS
// BOARD F HEALTH
,l . ............ OF ....... ..4.1-C�...r........................................................
(Fitrtifiratr of T o utpliattu
THIS IS TO CERTIFY, That the Individual Sewage Disposal System constructed
has been installed in accordance with the provisio(s
application for Disposal Works Construction Per it
THE ISSUANCE OF THIS CERTIFICATE S
SYSTEM WILL FUNCTION SATISFACTORY.
DATE..............................................................................
) or Repaired "\
--- --•------------------------•--------------------------•-
of TI 5 of he State Sanitary Code as describ the
No.. (•--•------- dated...... � �
1A L NOT BE CONSTRUED AS A GUARANTEE THAT THE
Inspector.