HomeMy WebLinkAboutApp-Permit-ComplianceNo. �. %. ! Fxs O.. �............
THE COMMONWEALTH OF MASSACHUSETTS
BOARD OF HEALTH
...........................................OF 171AK�'..�� a . i .................................
Appliration for Uispaoal Warks Toustrurtiun Famit
00
Application is hereby made for a Permit to Construct ( ) or Repair (Van Individual Sewage Disposal
System at ._.......
---------- ----
�jion -Address, ^ a y� or Lot No.
br1 n�G,1.�1 ]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... ............................ --- llons per person per day. Total daily flow -------------------------------------------- gallons.
Septic Tank — Liquid capacit..y _ :------ga ons Length---------------- Width .......... _..... Diameter ................ Depth ................
Disposal Trench — No .................. Widt .................... Total Length .................... Total leaching area .................... sq. ft.
Seepage Pit No -----_------------- ' meter................... Depth below inlet .................... Total leaching area .................. sq. ft.
Other Distribution box ( ) D sing 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.........................•--------------•---------------------._...----------------------------------------......----------------------........-•-----•---•-----••----•.
------------------------------------------------------------------------------------------------------------------- ------ --- ..•-- -• _..
Nature of Repairs or Alterations — Answer when applicable/-_ __E'j---r;.. ................................ 10
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Agreement:
The undersigned agrees to install the aforedescribed Individual Sewage Disposal System in accordance with
the provisions of TIT1Z- 5 of the State Sanitary Code — The undersigned further agrees not to place the system in
operation until a Certificate of Compliance has been issue41
by the board of health.
Signed..• .....
Application Approved By.._ .....
Application Disapproved for the f ollowin reasons:
---•--------------------------------------------------------------------•--•-----•----•-•---
Permit N
Date
Issued------------------ .....................................
Date
THE COMMONWEALTH OF MASSACHUSETTS
BOARD OF HEALTH
..................... I.................... OF .....................................................................................
Trr#iiira tr of T-ampliattrit
Tk�S T6 ff1 Y, T��e Individual Sewage Disposal System constructed ( ) or Repaired
by-------•---------'......--•..................................... -----..................................................... y.......... .... ..,
Installer
has been installed in accordance with the provisions of T ^LE 5 o The State Sanitary Code scr, in t
application for Disposal Works Construction Permit No.��_ �.-�__�--.-----•- dated. -D- ..-._.--: -- -- -----, --
THE ISSUANCE OF THIS CERTIFICATE SHALL NOT STRUE G ARAN EE T T THE
SYSTEM WILL I FUN9TION SAT CTORY.
- ...................
DATE .---
DATE........... ---•--