HomeMy WebLinkAboutApp-Permit-ComplianceNo.a-L%2........
— - THE COMMONWEALTH OF MASSACHUSETTS
BOAoRD OF, HEALTH
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Appliration for Disposal Works Tonstrurt' n Frrutit
Application is hereby made for a Permit to Construct
System at: �...._
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Installer
Type of Building
Dwelling —No. of Bedrooms......
Other — Type of Building .........
( ) or Repair ( an Individual Sewage Disposal
Address
Size Lot ............................ Sq. feet
Attic ( ) Garbage Grinder ( )
.................. Showers ( ) — Cafeteria ( )
Otherfixtures................................................---....................................................---•----....-----•
Design Flow. gal ns pe pens er day. otal daily flow..... gallons.
Septic Tank — Liquid capacity ............ ons ength...... ........ Width ................ Diameter ................ Depth ................
Disposal Trench — No ..................... W' th ..... ............. Tot Length .................... Total leaching area .................... sq. ft.
Seepage Pit No ..................... Diameter ................. Depth ow inlet.................... Total leaching area .................. sq. ft.
Other Distribution box ( ) D ing tank ( )
PercolationTest Results Perfo y ..................... .................................................... Date ........................................
Test Pit No. 1................minut s r inch Depth f Test Pit.................... Depth to ground water ........................
Test Pit No. 2................minutes per inch Depth of Test Pit .................... Depth to ground water ........................
Descriptionof Soil...................•--...........-----.................---•--...........---•--....--
........----•----•-......-•.......................•---------•-------.................------------•-•---------.........-----........._.. t...
Nature of Repairs or Alterations —Answer when a linable- ..-•--...•.....�.--••- ........
eP PP
Agreement :
The undersigned agrees to install the aforedescribed Individual Sewage Disposal System in accordance with
the provisions of TITLE 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 thd of th.
si-:......`"----------------- - --•-- - - - ..........._.. %�?:�` ....
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Dat
Application Approved By........ ...... ....._.x ..asr'
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Application Disapproved for the f oll zving'ij ►easons----------------------------------------------------------------------------------------------------------- ----
............................................................ ..........��//.......---........r..............•--•--.............--------......------•--.......... .....................................
Permit No.- �! �.- 7.�........ ...... r..r.... ..__........ Issued. ...............1 ...r.
THE COMMONWEALTH OF MASSACHUSETTS
BOARD OF HEALTH
.......................................... OF......:......................................:...............
(Urtif irmb of faontplianrr
0
by
THIS IS TO CERTIEW-,—That the Individual Sewage Disposal System constructed or Repaired
Installer
at- ........... eL... =t.. ............ _ :. ;� . = _•--•---•---• ,� !`:.:......::
has been installed in accordance with the provisions ofTI,5'LE }5 of The State Sanit
application for Disposal Works Construction Permit No._.b.- ..................... dat
THE ISSUANCE OF THIS CERTIFICATE SHALL NOT BE CONSTRUED AS
SYSTP , ILL FUNCTION SATISFACTORY. --
DATE. r �r r - ���... = ........................................ Inspector...:... ` ............... ...