HomeMy WebLinkAboutApp-Permit-ComplianceYAKWU I .H Ht/AL l H UtF i.
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Town Office Building CV CP
THE C§iaTOIY7NIN`t=A-L-TAF MASSQA2C%1ETTS
BOARD O HE T......H
...-..--...✓.
Appliration for Disp..
at Works Tonstrurtinn trrnti#
Application is
System at: _,I
) or Repair ( an Individual Sewage Disposal
Installer
Type of Building
Dwelling — No. of Bedrooms ............................................ Expansion Attic
Other — Type of Building ____________________________ No, of persons .......................
Other fixtures __._ _•
Address
Size Lot ............................ Sq. feet
Garbage Grinder ( )
--_ Showers ( ) — Cafeteria ( )
..-•---•--•--------••-----••-•---•-----.-.-•---.---••-----•--------•---------------------------------••--•-•-•.....-----••-•--....--•----••---•
Design Flow ............................................ gallons per person per day. Total daily flow ............................................ gallons.
Septic Tank —Liquid* capacity ............ gallohs 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__-
-- -------------------------•---------•--
Na f Repair r Alterations —Answer when ap icab
Agreement:
The undersigned agrees to install the aforedescribed
the provisions of TITiE 5 of the State Sanitary Code —'
operation until a Certificate of Compliance has been is
Signed...-._
Application Approved By.._.���
Application Disapproved for the following reasons:
by
Permit No .......
.............................................
-------•-------------------------•------•---------------------------......-----•-•--•----•--••----
le. ✓t/ ''__ hoc/ i –•.. �.... -'��
- --- - - --- --.........................
vidual Sewage Disposal System in accordance with
Irys�i
undersigned fur .e agrees not to place the system in
e Ia ,jr
- -- ---------- ----------------
a• f 1 DLD ea ..........
Date
--------------•-----•------------------------. __ _ __-. _--_--------
/ / r &S -.Date
ISSi3efL --1 l U._l. .........Date .... .........»
Date
THE COMMONWEALTH OF MASSACHUSETTS
ul c_
BOARD,3F/ HEALTH
............. ..........................OF,.:':....: % ..................................
(Irdif it r of (9aantplittnrr
THIS S TO CERT, 'at t4 I du4l' Sewage Disposal System constructed ( ) or Repaired
oo
has been installed in accordance with the provision. 'o ITLE 5 of The State Sanitary Code as described in the
application for Disposal Works Construction Permit No._-_��'........ . _-5 ...0 dated ----- 1f_I U1-t� �_________________________
THE ISSUANCE OF THIS CERTIFICATE SHALL NOT BE CONSTRUE® AS A GUARANTEE THAT THE
SYSTEM WILL FUNPTION SATISFACTORY.
DATE ........ I �� ��
_..�............................................. Inspector.... = w' ' ..............................