HomeMy WebLinkAboutApp-Permit-Compliancei—
,No.... .
THE COMMONWEALTH OF MASSACHUSETTS
BOARD OF HEALTH
OF.......................................................•---------------................._.
Appliration for Uwpooal Workfi Tmotrnrtiun Frruat
Application is hereby made for a Permit to Construct ( ) or Repair (X an Individual Sewage Disposal
System at:
------------ or Lot -No
or .
I
•.............•---`--•------------.............------.
Address
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---------------------------------•---•---------------------•-----------•-----------------------------------------------•------------------------------------------------
-----------------------------------------------------------••-•--••--------•---•••-•••--•--------•-----.
---•-P�_7
----------•...
Nature of Repairs or Alterations — Answer when applicable.--... Ql --- -------------------- -------------
Agreement :
The undersigned agrees to install the aforedescribed Individual Sewage Disposal System in accordance with
therovisions of IIT E,
p 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.
e/ J Date
`�\/ r
Application Approved By---'•------• _---------------•-.------
-My h Date
Application Disapproved for the following reasons:--------•-----••----•------•--••--------••---•---•••------•---•-••••-----------••---•---•-----------------------
PermitNo---------------------------------------------------------
----...---------------------------------------•------•-------•---•• •-•-•------...----•• ••-
Date
Issued--------------------------------------------------------
Date
THE COMMONWEALTH OF MASSACHUSETTS .
BOARD OF HEALTH
.......................................... OF ................................................. I ...................................
Trr#ifiratr of Tompliaurr
THIS IS TO CE�ZT7Y, That the Individual Sewage Disposal System constructed ( ) or Repaired
/ //
by ------------------.. --
/ , s -atter
has been installed in accordance with the provisions of TI F > of ��etateanitary Code s des ibed in the
application for Disposal Works Construction Permit No.____._- dated---
_
�.________________
THE ISSUANCE OF THIS CERTIFICATE SHALL NOT BE CONSTRUED, A G ARA TEE THAT THE
SYSTEM WILL FUNCTION SATISFACTORY.
DATE....--------•----------------------...4----------------------------------------- Inspector