HomeMy WebLinkAboutApp-Permit-ComplianceTHE COMMONWEALTH OF MASSACHUSETTS
OARD F HEALTH
............... ... .C�.t�... -OF ...... .!. ............
Appliration for Bispoiital ork on a�
Application is hereby made fo,r)a Permit to Construct
System at:>,... ..... �.1� ![�. ...............
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or Repair ( V) an Individual Sewage Disposal
LoT C"l MAP 121
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or Lot No.
Address
nstaller 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 ............ 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. 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 .___.__.............____
Description of Soil ------------------------------------------
............................................................... .................................................. --------------•-------•-••-•-----•--•-•--............................................
Nature of Repairs or Alterations —Answer when applicable ___vT -------- --________>C._ -
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Agreement :
The undersigned agrees to install the aforedescribed Individual Sewage Disposal System in accordance with
the provisions of TITTIE 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 .,
Application Approved By ........... � �) ------ --•----•----------------------------------�j— 1� ....
Application Disapproved for thji6�d4-0"in,0ffdSV6r--------------------------------------------------------•------------------•--------.....----- ----------------
..................................
Date
Permit No --------------------------------------------------------- Issued----------•-----------------
.......................................................
Date
THE COMMONWEALTH OF MASSACHUSETTS
,1 BOARD OF
/• /ZHEALTH
...........OF.....�I�61.a1k
......................................
Trr#ifir fof
Tontplittnrr
THIS IS T RTIFY, T he Individual Sewage Disposal System constructed ( ) or Repaired
./ ��1.....-----------------------------------------------------------------------------------------•------------------------•-•-----------..._
Installer
_... 9 �"."----.. .. ,— ---_-----------------
17as. -
Kas been installed in accordance with the provisions of TIT F 5 of The State Sanitary Code as described in the
application for Disposal Works Construction Permit No.-/�_ ""_,�------.... dated __---___-__------------------------------------
THE ISSUANCE OF THIS CERTIFICATE SHALL NOT BE CONSTRUE® AS A GUARANTEE THAT THE
SYSTEM WILL FUNCTION SATISFACTORY.
DATE................................................................................ Inspector