HomeMy WebLinkAboutApp-Permit-ComplianceYF RIM, "' .
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No .................... South .....
THE COMMONWEALTH OF MASSACHUSETTS
_ BI ARD HE H
................f�.%..'f/..........OF.......... �....................................
Applutt#ion for Mop �tlWorks Tons#rwtiun 1hrmft
Application is hereby made for a Permit to Construct ( ) or Repair ( Individual Sewage Disposal
System at
...�' ... e!. , . ....1....... ................................ ....M .... `:. ...xis....._... ............... ........
,Location - Address y r Lot o. ----
P
... . . ............. . .... WO n.� ......
pyy �.� //,,
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. I...............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 --------------•----------------
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NatuvE.of ReAairs or Alteratigna —Answer when
Agreement: "
The undersigned agrees to install the aforedescribed
the provisions of TITLE 5 of the State Sanitary Code .
operation until a Certificate of Compliance has n i ed 1
L
Application Approved By....
Application Disapproved for the following reasons:..
q
Permit No.... - �?� F ------•----.•....-_-_---
Sewage Disposal System in accordance with
'ned Ertl er agrees. not to place the system in
Date
Date
Issued_ ..... 21 .1. SS ..........................
Date
THE COMMONWEALTH OF MASSACHUSETTS
BOARD OF, HEALTH
��..............................................
(Intifit *` of fad mpliane
r
Tl�f TO CER ,-&,a, That h�,�dNi�lual Sewage Disposal System constructed ( ) or Repaired ( "'
s J _ j Installer
�"
_- ----------------------------------------. ...........•.
-
has been installed in accordance with the provisions of TTTLE ,.of The State Sanitary Code asdes ibed in the
application for. Disposal Works Construction Permit No ---- .7------ _._� ............... dated... ..... .......................
THE ISSUANCE OF THIS CERTIFICATE SHALL NOT BE. CONSTRUED,AS A GUARANTEE THAT THE
SYSTEM WILL FUNCTION SATISFACTORY.
' r ............... Ins ector :- -----
DATE.--•...... 'i..... p