HomeMy WebLinkAboutApp-Permit-ComplianceTHE COMMONWEALTH OF MASSACHUSETTS
BOARD OF HEALTH
.................................. OF ... %,-/...I.Ma `l" .........................................
Appliration for Disposal Works Tontrudion 1rrntit
Application is hereby made for a Permit to Construct ( ) or Repair (G/j'*"an Individual Sewage Disposal
System at :L, 9-
-Location - Addres
................ �_-� q. ..... 1J c .�
...........................
_...
`.9f , , V� (-,w
Installer
Type of Building
Dwelling — No. of Bedrooms
Other — Type of Building ...
Other fixtures (inut
Design Flow -•................•---------
Septic Tank — Liquid capaci
Disposal Trench — No..........
Seepage Pit No .....................
Other Distribution box ( )
Percolation Test Results
Test Pit No. 1 ................
Test Pit No. 2................
or Lot No.
......_ i��l.....: e„
........................ naar ..
..._.......
IA..............................................................
nadTess
Size Lot ............................ Sq. feet
.....Expansion Attic ( ) Garbage Grinder ( )
of persons ............................ Showers ( ) — Cafeteria ( )
.........-•----•..............................................•--•-----•-..................••---•....-•--............--
s person per day. Total daily flow............................................gallons.
ength................ Width ................ Diameter ................ Depth..------....----
.............. Total Length .................... Total leaching area .................... sq. ft.
........ Depth below inlet .................... Total leaching area .................. sq. ft.
ng nk ( )
Date.--• ........................................
inch Depth of Test Pit .................... Depth to ground water............
inch Depth of Test Pit .................... Depth to ground water............
Descriptionof Soil ............................................................................................
.........................................••------..............-----................------..........-----.....------•----......------•---•-----------------------...........
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Nature of Repairs or Alterations —Answer when applicable .....:............`..
............. 14 ..........................
Agreement:
The undersigned agrees to install the aforedescribed Individual Sewage Disposal System in accordance with
the provisions of TITLE 5 of the State Sanitary Code — The undersigned further agrees not to place the system in
operation until a Certificate of Compliance has tissue/d by the boar of health. J
Application Approved?....'.. �...`,
Application Disapproved for the f ollouring reasons:
Date
_----------------------------------------�1..---------....------.......--------..--�...------•--- .------------...-._......... ---
Dom... ------
PermitNo. ..-. 3 � •. ...... ...... _........ ........ Issued...... .1 _.........---------.._
THE COMMONWEALTH OF MASSACHUSETTS
BOARD OF HEALTH
OF.... �..Y�...........................................................
T ertif iratr of Tontplinurr ,
THIS IS TO CERTIF. , hat the Ind:vi al Sewage. Disposal System constructed ( ) or Repaired (4-)
Lat_c� Installer
{
has been installed in accordance with the provisions of T ,tj of The State Sanitar ode its c�eri�bed in the
application for Disposal Works Construction Permit No.. ----- ........................ dated. ?� ! .. 1�?.j..._._...__.._....._.__..
THE ISSUANCE OF THIS CERTIFICATE SHALL NOT BE CONSTRUED AS A GUARANTEE THAT THE
SYSTEM WILL FUNCTION SATISFACTORY.
j
DATE............ .:.'..---.--•----•....-••-------------•-•--•-•-•------- Inspector.....- I j............................. '.-•:.._'.........----.................