HomeMy WebLinkAboutApp-Permit-ComplianceNo. - - - •�� Fss....l..
THE COMMONWEALTH OF MASSACHUSETTS
BOARD �F HEALTH
...........1 -OF ....... ....
.......�:-�--------------------..-
Appliration for Dispoiia1 Vorkg Tonotrartion ramit
Application is hereby made for a Perm i Construct 6'Q or Repair ( ) an Individual Sewage Disposal
5 O System at: �° %- -•- ---•--
- - Xt
------
ner v Address
a.-•-- ............................................. ------•.•................................... Address............... -----------------------
Installer
Type of Building Size Lot ............................Sq. feet
U Dwelling — No. of Bedrooms...._.__. ..........................Expansion Attic ( ) Garbage Grinder ( )
aa, Other — Type of Building ---------------------------- No. of persons ................ .----------- Showers ( ) — Cafeteria ( )
Otherfixtures --------------- ------------------------------------------------------------------_ -------------------------------------------------------------
W Design Flow.. ---------- ------.-----gallons per person per day. Total daily flow............................................gallons.
WSeptic Tank — Liquid capacity./MC&allons Length ................ Width ................ Diameter ................ Depth ................
x Disposal Trench — No. --..--_-------___. Width .................... Total Length .................... Total leaching area .................... sq. ft.
Seepage Pit No -----------------_-- Diameter .................... Depth below inlet .................... Total leaching area .................. sq. ft.
Z 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 ........................
w, Test Pit No. 2................minutes per inch Depth of Test Pit .................... Depth to ground water ........................
P4----------------•---------•---••-•------•-----------•••---------------.....--------.........--•----- .........................................................
0 Description of Soil ........................................................................................................................................................................
U' ----------------------------------------•--•-----------••----..........................................................................................................................................
W---------•-----------------------------------------------------------------------------------•----------------------------------------------------------------••----- ---------------------------------
UNature of Repairs or Alterations — Answer when applicable...............................................................................................
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Agreement:
The undersigned agrees to install the aforedescribed Individual Sewage Disposal System in accordance with
the provisions of TI TLE, 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.
Sivned...................................................................................... ................................
Date
Application Approved By .................. ---....�:...-- ---------------------........ � SDacJY te � --
Application Disapproved for the following reasons--------------------------------------------------------------------------------------.........................
....................................... ............. ........................................ ---................................................... ....................................................
Date
PermitNo --------------------------------------------------------- Issued-------- -----.........-----•---------•- •-•---•--------
Date
THE COMMONWEALTH OF MASSACHUSETTS
BOARD OF HEALTH
............/ l_%4/t ). e �j....OF............ ./........_............... ....................................
�rrtifira of T.unt�rlianr�e
THIS IS TO CERTIFY, That the Individual Sewage Disposal System constructed (}� or Repaired ( )
by ---------------------
Installer
at----•----------------------------------•--------------------------•----------------------------------- ---------------------------•-------------------------------------------------------------------
has been installed in accordance with the provisions of TIT �� � State Sanitary ..Co e a descrili e !, the
application for Disposal Works Construction Permit No;/ dated_�__.___`____C�'_____________
THE ISSUANCE OF THIS CERTIFICATE SHALL NOT BE CONSTRUED AS A GUARANTEE THAT THE
SYSTEM WILL FUNCTION SATISFACTORY. �
DATE ..............
f `t�:?a Inspector.