HomeMy WebLinkAboutApp-Permit-ComplianceNo..._�! .Y.... FES.r. ::.................
THE COMMONWEALTH OF MASSACHUSETTS
BOAR® OF HEALTH
----------------- OF_ ....X/I,1 ...__.......-------------------------------
Appliration for Uh4paiitt1 Warks Tonotrurti.an Vautit
Application is hereby made for a Permit to Construct ( ) or Repair ( �an Individual Sewage Disposal
System at:
r'd
Location - Address
�..,
..........
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Installer
Type of Building
Dwelling — No. of Bedrooms .........
...............
A dress
Size Lot ---------------------------- Sq. feet
Expansion Attic ( ) Garbage Grinder ( )
Other — Type of Building ____________________________ No. of persons ........................... .. Showers ( ) — Cafeteria ( )
Otherfixtures------------------------------------------------------------------•---•---------•-•----------•------•-•--•-•-••---....._......----•-----------........
Design Flow.---.......�~76 ......................gallons per person per day. Total daily flow .......... G.......... _............ 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..............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 ........................
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Descriptionof Soil ........................................................................................................................................................................
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---- -----
Nature of Repairs or Alterations — Answer whea_j plicable....� ��1. ..___._e�_._._dam'_.9>,.,;
Agreement:
The undersigned agrees to install the aforedescri d ndividual S wa Disposal System in accordance with
the provisions of TITLE 5 of the State Sanitary Co ,e'— he deed,, ",.-cher `rees not to place the s stem in
operation until a Certificate of Compliance has bee i d b e bol d alt
Sig ned.....
Date
Application Approved By---��--- --- }�- 7= k-?
.
Date
Application Disapproved for the following reason `-----------------------------------------------------------------------------••-----------------............--
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Date
PermitNo... - � --�--------------------------- Issued ....... ....................
Date
THE COMMONWEALTH OF MASSACHUSETTS
BOARD OF HEALTH
.................... O ........................................
�ler�ifirtt�le n� �unt�r�i�tnrr
THIS IS TO CERTIFY, That the Individual Sewage Disposal System constructed ( ) or Repaired. (_�
Installer
at 1�� Installer
... ---------------------•--•---------------------------------•-------------
has been installed in accordance with the provisions of TITLE. 5 of The State Sanitary Code as described in the
application_ for Disposal Works Construction Permit No.__d!_.._1S!................. dated ----- ................
THE ISSUANCE OF THIS CERTIFICATE SMALL NOT BE CONSTRUED AS A GUARANTEE THAT THE
SYSTEM WILL FUNCTION SATISFACTORY.
DATE.......[?. -f-I................................................... Inspector . - .._....------------•-------•---