HomeMy WebLinkAboutApp-Permit-CompliancesFRXE ...... .. Id
THE COMMONWEALTH OF MASSA-C-HUSETTS
BOARD OF HEALTH
..............................----.---...OF..........................._._........------------------------......_..._......._------...
Appliration for Uispoatal Vorkg Tontratrtion thrutit
Application is hereby made for a Permit to Construct ( ) or Repair(^) aann Individual Sewage Disposal
System at: �j � LJ ........................................
.. ��
- Address
Installer `
Type of Building
Dwelling —No. of Bedrooms
Other —Type of Building ---
Other fixtures
or
Address
Address
Size Lot ---------------------------- Sq. feet
........................Expansion Attic ( ) Garbage Grinder ( )
..... No. of persons ............................ Showers ( ) — Cafeteria ( )
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 ................ fninutes 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-_--_-
-------------------------------•-------------------------------------------------------------------------------------------------------fal
...........................
Agreement:
The undersigned agrees to install the aforedescribed Individual Sewage Dispystemin accordance with
("iT rim
the provisions of T :1 7 5 of the State Sanitary Code — The undersigned further agrees not to place the system in
operation until a Certificate of Compliance has bee issued by th board health. c.
Signed I ------- ------ P 1
1
Application Approved By.... ..•• .--•-•---------------------•-----•._...------------------•-----.
. Date
Application Disapproved for the f ollowin reasons:.------•------•----•-•----------------------•----------------•------------•------------••----------------••----
Permit No .......
Date
Issued.......................................................
Date
THE COMMONWEALTH OF MASSACHUSETTS
BOARD OF HEALTH
.......................................... OF ....................................................................................
__frrtifiratr of Tomptiatty
THIS IS TO OERTIFY Tha the Individual Sewage Disposal System constructed
by................... 1 .......... -•........� . .............................. ............................. .....................
at---...-•----.....-•------------- �•.......
has been installed in ac' co�dance with the provisions o TI 7' LF;
application. for Disposal Works Construction Permit No.-�� -
THE ISSUANCE OF THIS CERTIFICATE SHALL NOT
SYSTEM WILL FUIOCTION SATISFACTORY.
DATE---------. ------------------------------- Inspe(
) or Repaired