HomeMy WebLinkAboutApp-Permit-ComplianceNo.. . ?�.. a....... Fmc..Z.� �. .
THE COMMONWEALTH OF MASSACHUSETTS
BOARD OF HEALTH
....OF... i .. ........
Alipliration for 11ispas l 19orks Tonsirur#ion 1rrnti#
Application is hereby made for a Permit to Construct ( ) or Repair (1,�an Individual Sewage Disposal
System at
V�
�jo
ation - Address
Installer
Type of Building
Dwelling — No. of Bedroo
Other — Type of Building
Other fixtures ....
b.....-,1 ............................................ ........
ddress
.......................................................
Address
Size Lot ............................ Sq. feet
........ Expansion Attic ( ) Garbage Grinder ( )
of persons ............................ Showers ( ) — Cafeteria ( )
Design Flow ....................................:... ..g r person per day. Total daily flow ............................................ gallons.
Septic Tank — Liquid capacity _________.. lon Length ................ Width ---------------- Diameter ................ Depth ................
Disposal Trench — No . ................Zidth------ ..._._..._.. Total Length............._._.._. Total leaching area.........._.........sq. ft.
Seepage Pit No ..................... iam.......__.._.... Depth below inlet---.._.............. Total leaching area........ ---.._....sq. ft.
Other Distribution box ( ) Dosing tank ( ) -
PercolationTest Results d 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_.
•---------------------------------------------------•----•-------------------------................----•----/ t
Nature of Repairs or Alterations —Answer when applicable___[ ..�. � �f �____....................................---.
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Agreement:
The undersigned agrees to install the aforedescribed Individual Sewage Disposal System in accordance with
the provisions of TITUj 5 of the State Sanitary Code — The undersigned further agrees not to place the system in
operation until a Certificate of Compliance has been issue the board of health.
C +YrSigne .-. _--- _ • ---- -•---------------•------•...----
L D
Application Approved By.....- -------..... a l
Date
Application Disapproved for IhV f olly,�ving reasons: ...............................................................................................................
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%9Date
gQ�nc� �--6
Permit No.._D SI ----ST. U -•--- ._.... Issu- -
DateZ� --------------- j ..
THE COMMONWEALTH OF MASSACHUSETTS
BOARD O,,F�� HEALTH
.......................................... OF.... L:!�/V ......................................
Tntifirw of Tomplittnrr
THIS IS TO CERTPTha the I ivid Sewage Disposal S7stem constructed
b•6 .... .�.! 1.-------------------------------------------------------------.
Installer
rw •-----------
has been installed in accordance witTi the provisions of TITLE ryry5 of The State Sami
application for Disposal Works Construction Permit No. -A.8- A--------------------- dateT�-
THE ISSUANCE OF THIS CERTIFICATE SHALL NOT BE CONSTRUED A!�"
SYSTEM ILL UNCTION SATISFACTORY. �_„
DATd Pan ....................................... Inspector.-�'.-------
..--
or Repaired
THAT THE