Loading...
The URL can be used to link to this page
Your browser does not support the video tag.
Home
My WebLink
About
App-Permit-Compliance
k, 4-- 471 No...�l.-. --- Fps....... 5 ............... THE COM ONWEAL MASSACHUSETTS BOARD OF HEALTH ....... ........................O F..............................I.........-------------•-•--..._.._.__..................... Appliration for Dislivii al Workri Tunstrn.rtion Errant Application is hereby made for a Permit to Construct ( ) or Repair(�an Individual Sewage Disposal 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 ........................ Description of Soil--- ------•------------------------------------------•--•--------------------------------------•-•----------•••--------- . f -/-- Nature of R irs or Alterations — Answer wh applicable _.___..__.. C ©�� _..___._. __ .�.(-------_-------- ----- Agreement : The undersigned agrees to install the aforedescribed Individual Sewage Disposal System in accordance with the provisions of TITIN 5 of the State Sanitary Code — The undersigned further agrees not to place the system in operation until a Certificate of Compliance has been iss b he boar ealth. Sined--------------- ............................................. .............. Date Application Approved By .......................... ... --• •.. . . .... ............... ............ ---------- .�� � � Date Application Disapproved for the following reasons: ..................... y._._.----.._......___.__..-__....__ .---------------------••-•...--•-•----•--.._.......-•---••-•------•--•---------------------------------------------------------------•---------------------...------------------.. ? / - Date Permit No..... ' 7�................................. Issued --•--1 ® (........................ Date THE COMMONWEALTH OF MASSACHUSETTS BOARD OF HEALTH .......................................... OF ..................................................................................... (9rdifiratr of Tootltlittnrr THIS IS TO CERTIFY, That the Individual Sewage Disposal System constructed ( ) or Repaired ) by-------------------------•----•---------------------•--•-----•--•-- -�E- --s..7.4. ------ ---------------------------------------------------..........------......--•----------------•-- Installer 15 at----------------------------------------------------------------------------- { =� --------- f ---------------------------------------------------------- has been installed in accordance with the provisions of TITLE 5 0fThe State Sanitary Code as descri ed in the application for Disposal Works Construction Permit No ... � j_r, -734r-( --------- dated ------------ __ __...,:................ THE ISSUANCE OF THIS CERTIFICATE SHALL NOT 13E ST UE® A GUARANTEE T THE SYSTEMA WILL FU TION AT SFACTORY. DATE .......... .l-- ---------------------------- Inspector ..__ . -------•----------------