HomeMy WebLinkAboutApp-Permit-Compliancen ..IL ----- Fps..... s..........._
THE COMMONWEALTH OF MASS CHU E
A S TTS
B ARD OF HEALTH
..............1..0. ....OF ................
... _........_ .
.............
Applilratiun for Bispaoal Morks Tonstradivan jrrutit
Application is hereby made for a Permit to Construct or Repair ( ) an Individual Sewage Disposal
Syl
tem at _._.._..... _ .. ... ...... .......... .... .........._..
............ ...... .. !L� tion . ...........................................
............................. ..........----------------- Lot No. ......................... .....«.......
Owner Address
Installer Address �• •�-•-•
Type of BuildingSize ....Sq. feet
Dwelling —No. of Bedrooms..........3 ..................................Expansion Attic ( ) Garbage Grinder ( )
Other —Type of Building ............................ No. of persons ............................ Showers ( ) — Cafeteria ( )
Other fixtures ......................................
..---••--•-•. . . . .... .........•------
Design Flow ................ 1_%. ................. gallons perms per day. Total daily flow ............. _-7..3 ................. gallons.
Septic Tank — Liquid' ca.pacitylO00_.gallons Length ................ Width; ............... Diameter ................ Depth ................
Disposal Trench — No ..................... Width .................... Total Length .................... Total leaching area ......... ........... sq. ft.
Seepage Pit No ........ I........... Diameter ....... 10....... Depth below inlet ..... E........... Total leaching area_�7 .�Psq. ft.
Other Distribution box (>Q Dosing tank( ) ��zsli='J�
Percolation Test Results Performed by ...... .l..IN-. ..............r� __..........._..... Date......._...._......................
Test Pit No. 1... L._____.minutes per inch Depth of Test Pit .... .... V, Depth to ground water.°
Test Pit No. 2 ... i!��minutes per inch Depth of Test Pit ..... L.q-,q..... Depth to ground water....VV..............
-------------------------------------------------------•--------------......._....---.......--------•---------------...--•--•------------------------------.
Description of Soil ...................................................
................................................................................................................................................................................................
Nature of Repairs or Alterations — Answer when applicable --_-_-_---_-•------------------------------•_-_-_-____•-___-_----:_-_-_-__--_,_____-___
Agreement :
The undersigned agrees to install the aforedescribed Individual Sewage Disposal System in accordance with
the provisions of TITLE 5 of the State Sanitary Code — The undersigned further agrees not to place the system in
operation until a Certificate of Compliance h b ssued the board of health.
Application Approved B ` ..... -- • --•---•..............
Application Disapproved for the following reasons: ........... d ............................................
PermitNo..r... I .. .........................•---------
Date
Date
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1L'Tate
TM THE9COMKONWEALTH OF MASSACHUSETTS
,�--�- BOARD OF HEALTH.:
Jo.............................:..OF.... f?!Eft!tQtaT�.::...,.....:'......:..
(9rdifiratt. of Toutpliattre
S TO CERTIFY, That the Ind vidu Sewage Disposal System` constructed (X) or Repaired ( )
C 11AltfJU �' £7 'Mplt7�( Ing er -- y
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..
has been installed in accordance with the provisions of of The State Sanita y o e d ri the
9 ,application-'forDisposal Works Construction Permit Now- ........ I....................... date �_ ....._...
THE ISSUANCE OF THIS CERTIFICATE SHALL NOT BE CONSTRUED AS ' U TEE THAT THE
SYSTE WILL FUNCTION SATISFACTORY.
DATE.. Inspect @x,