HomeMy WebLinkAboutApp-Permit-ComplianceNo.... ..7...�
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THE COMMONWEALTH OF MASSACHUSETTS
BOARD OF HEALTH
........:.:..............-yL�........OF....uo(,.4. -o 1 Gt:1/..,............................................
Appliration for Disposal 19orks Tonstrnr#iun Frrnti#
Application is hereby made for a Permit to Construct ( ) or Repair ( C� Individual Sewage Disposal
System at:
--------------------
---------------
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....._......gallonsength................ Width ................ Diameter ................ Depth ................
Disposal Trench — No. _./............... Width ...... Total Length ----- :2 ..(o .... 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 ........................
Descriptionof Soil --------------------------------------------------------------------------------------
-----••----------• -----`.....................•••------•---------•--•------•••••-----...----•-----...----•--••----------------•--- ..................................................
Nature of Repairs or Alterations -Answer when applicable___.._/ %_____________ ___Z � e .....�T .,SAIE
,` -
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 t to place the system in
operation until a Certificate of Compliance ssued by thet�parqpL4je< .
Application Approved By
Application Disapproved for the
— Da------ -------
Due
Permit No..... Zl_...z/-----------------------_...... issued .... ............. — �)- --
D
THE COMMONWEALTH OF MASSACHUSETTS
BOARD OF HEALTH
.��16 ..... .....OF.........../ .V.. ..... z. .....................................
Trrxifiraw of Toutpliam
THIS JTOO CER Y, that t e Individual Sewage Disposal System constructed ( ) or Repaired ( .
by.....................1..�.--'--- ------------------------------------------------- ------------------------------------------------------------------- _-------._
Installer
-------
has been installed in accordance with the provisions of TITt_70
5 he State Sanitary Cod as described in the
application for Disposal Works Construction Permit No ------- . .................. dated ..... 3 —3: S[ 7_.__..............
THE ISSUANCE OF THIS CERTIFICATE SHALL NOT BE CONSTRUED AS A GUARANTEE THAT THE
SYSTEM WILL FUNCTION SATISFACTORY.
DATE...........................................'-----...---.....--------------..... Inspector