HomeMy WebLinkAboutApp-Permit-ComplianceTHE COMMONWEALTH OF MASSACHUSETTS
BOARD F HE TH
-----------OF......0.............................................
Appliratiaan for Dia paaaittl lVarkri Tonstrnrtion Frrmit
Application is hereby made for a Permit to Construct ( ) or Repair (kr< Individual Sewage Disposal
System at
A..........................................
", crT lL'1c� 5
Location . Address
t No.X
.---•-•-----•--•-•-. ��rf�lttllPfr`.G�rI_c11... .........f7f!..�..•..
Installer Address
Type of Building Size Lot............................Sq. feet
Dwelling — No. of Bedrooms............................................Expansion Attic ( ) Garbage Grinder ( )
aOther —Type of Building ............................ No. of persons ............................ Showers ( ) — Cafeteria ( )
i Other fixtures
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Design Flow ............................................ gallons per person per day. Total daily flow ............................................ gallons.
Septic Tank — Liquid capacity ............ gallons Length ................ Width ................ Diameter................ Depth ................
1 Disposal Trench — No ..................... Width .................... Total Length .................... Total leaching area .................... sq. ft.
i
Seepage Pit No ..................... Diameter .................... Depth below inlet .................... Total leaching area .................. sq. ft.
Other Distribution box ( ) Dosing tank ( )
i Percolation Test Results Performed by.......................................................................... Date ........................................
jTest 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 ........................
aDescription of Soil.............................•..................---------------.....---••----•-•----------------•-----------------------•----------------•-----------........----•---...
i
1.........................................................................................................................................................................................................
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N of epairs or Alterations —Answer when applicabl .f%l �F�"_....X/!!�!1....- .. _____11.1___1
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Agreement:
The undersigned agrees to install the aforedescribe ndividual Sewage Disposal System in accordance with
the provisions of TITLE
5 of the State Sanitary Code he.. n fu tlier agr es not to place the system in
operation until a Certificate of Compliance has been ' s y
Application Approved By..,eY�..... 1!` ....L
Application Disapproved for the following reasons:....
Permit No....... �` ..:1..1' ----•-•................
Da e
Date
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.------------------------•-----•--•---------------•------...-------------•-------
Date
Issued _.......... �.....
.-...... -
Date
., 11..,1111111 1111
THE COMMONWEALTH OF MASSACHUSETTS
BOARD OF HEALT
1111-----•'_'' -�.
.l)l'`��!'�.....................................................
........ O F...........
(Intifiratr of (D"'U plittnrr
TI LS TO CE . I,,4� That t1noividual Sewage Disposal System constructed ( ) or Repaired (ILr
by
= L_ ... ..... _.........................................................................
has been installed in accordance with the provisif TITLE, 5 of The State Sanitary Code as described in the
application for Disposal Works Construction Pet rt No ..... 2`/.._. Vis._:.-------------- dated....... -. .r -... �,1'.......
THE ISSUANCE OF THIS CERTIFICATE SHALL NOT BE CONSTRUED AS A GUARANTEE THAT THE
SYSTEM WILL FUNCTION SATISFACTORY.
DATE--... -��----------------------------------------------- Inspector ............................... .........
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