HomeMy WebLinkAboutApp-Permit-ComplianceNOZ3-1�� FRic ... /,–:
THE COMMONWEALTH OF MASSACHUSETTS
<-� BOARD OF, HEALTH
i- 4.,jT...------...OF........................ ..Aa &\%
Appliration for Uhipasal 10orks Tuastrnrtion Famit
Application is hereby made for a Permit to Construct ( ) or Repair ( Z_�-an Individual Sewage Disposal
System at:
Lo ..a...
. t Na
2 •. -...................................
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........_._.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 ........................
Descriptionof Soil--------------------------------------------------------------------------------------------
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Nat re Repairs or Alterations —Answer when applicable ------------- .... c .___ ..._1': ........................
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l-------- ST -6n :�---------- �_C � -plc¢ `------------------------------------------------------------ -----------------------------------------
Agreement :
The undersigned agrees to install the aforedescribed Individual Sewage Disposal System in accordance with
the provisions of TITI.B 5 of the State Sanitary Code — The undersigned jWther agrees not to place the system in
operation until a Certificate of Compliance has been issu d y 4e board
Signed _. -------------
---------------- ----�---•--•-
Date
ApplicationApproved By..- •- - -•- --•.........✓ ..... • ...... ..................................... ...........
Date
Application Disapproved for the fol owing reasons- --------------••----....-------------------------------------•------------------•---.....---•----•--------------
--------------------------------•---------------......--------------------•---------------••-----------....------.........-----------------------•---------------------------------------------•-•------.
Date
i
Permit No ------ ------------------------------------------ Issued.-----`--'-----..._.£-----�,._.i'._..................
Date
THE COMMONWEALTH OF MASSACHUSETTS
BOARD OF HEALTH
......... .......... OF...... k'i'iTO.......................................
C�rrii�irtt�le of f�unt�r�i�nr�e
THI I TO CERTIFY, That the Individual Sewage Disposal S7stem constructed ( ) or Repaired
by//....1...��.....................................•. ------•-------------------------•--•--•------..............-----...........----....--•-•--------•-•-•--
/ Installer
has been installed in accordancewith the provisions of TITLE 5 of The State Sanitary Code as described the
application for Disposal Works Construction Permit No..._��.__"'_..__.__-,%,Cf .............. dated__..___ ...................................
THE ISSUANCE OF THIS CERTIFICATE SHALT. NOT BE CONSTRUE® AS A GUARANTEE THAT THE
SYSTEM WILL FUNCTION SATISFACTORY.
DATE....
Inspector,