HomeMy WebLinkAboutApp-Permit-Compliancet.: t
No R
7X0 THE COMMONWEALTH OF MASSACHUSETTS
)BOARD OF .HEALTH
CFI. ------..OF .................... ..., ..... -------------------------------------------
Appliration for Uiap s ork,i Tomitrur#ion thrmit
Application is hereby made for a Permit to Con ruct ( ) or Repair X an Individual Sewage Disposal
System at: •-
e Location Address s
.Owner
or Lot No.
Address
Installer Address
Type of Bui ing 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 ................ 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.__".
------------- -•-• .. : d .
Agreement:
The undersigned agrees to install the aforedescribed Individual Sewage Disposal System in accordance with
the provisions of TIT?.1 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 the board of health.
,..
Signed...................................................................................... --------------------------------
Date
Approved By ....... - ` .• r �... _Date _
--•- (% ------
HHr r--------•----•--------•--'-----•-'--••------'---......---•--•-----......-Da e
Application Disapproved for theooiv®gi�e�ns__________________
-----------------------'-----...---'----------------------------------•-------------------------'---'---.."----------------------------- ............................................................
Date
PermitNo ......................................................... Issued .......................................................
Date
THE COMMONWEALTH OF MASSACHUSETTS
BOARD OF HEALTH
'......-
....................................................................Or.... OF...........
Cntifirtt f
Toutpliatta
THIS, IS TO CERTIFY, That the Individual Sewage Disposal System constructed ( ) or Repaired ("A
by, ........../ . r .----•-----------.................................................................
Installer -•u ' a
at..- �,� 49,
;» s '---------------- `1..-2 - . ......•----------
r •-mac
has been installed in accordance with the provisi� of TITLE_ of h�e State Sanitary Codas ,described in the .
application for Disposal Works Construction Permit Nom "'�__ ________ da.ted_r'`/' "` __
- ----
THE ISSUANCE OF THIS CERTIFICATE SH NOT BE CONSTRUE® AS A GUARANTEE THAT THE
SYSTEM WILL FUNCTION SATISFACTORY.
DATE............................
Inspector