HomeMy WebLinkAboutApp-Permit-ComplianceNo;7_ Fps......
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THE COMMONWEALTH OF MASSACHUSETTS
BOARD OF HEALTH
---------------..... OF........................................... ..............................................
ApplirFaiion for Disposal 10orkg Tonarnrtion 1hrmit
Application is hereby made for a Permit to Construct ( ) or Repair N an Individual Sewage Disposal
System at
Location - Add ess or Lot No.
. ....... ..... .......... -•-----------------------------------------•-----•-........_.----...............................--
Owner Address
-t=- -.S�L�_..............................................•._......---................................................................
Installer Address
Type of Building Size Lot ............................Sq. feet
Dwelling —No. of Bedrooms............................................Expansion Attic ( ) Garbage Grinder ( )
Other — Type of Building ............................ No. of persons ............................ Showers ( ) — Cafeteria ( )
Otherfixtures .---•------•---------------•------------------•-------•-•-----------------------------------------------------------------------------.._...--I-------
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---------------- 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 .___.._____..._.._.._._.
---•--------------------------•------------•---------------•---........--•-•-----•--•-----------•-----•------------------------------•--......--------------•
Descriptionof Soil---------------------------------------------------------------------------------------_-----
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-----------------------------------------------------------------------------------------------------------------------�---f- -- ------ --------------------------- •-•---
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'T': y g g p y of the State Sanitary Code —The undersigned further agrees not to lace the system in
operation until a Certificate of Compliance has been issued by the board of health.
Signed...................................................................................... -----------_------------
Date
L
Application Approved By----- 4 �� ---------------------------- 6Date
Application Disapproved for thW ga11& Qfk ------------------------------------------------------- ---------------------------------------------------------
--•---•---------•--------------------------•-------------•---------•----------••---------•-•-•-----....---•-•-------- --••--•-•----•--•--------•-----•-•-----•--......--------•-------------------------
Date
PermitNo --------------------------------------------------------- Issued --------------------------------------------------------
Date
THE COMMONWEALTH OF MASSACHUSETTS
BOARD OF HEALTH
.......................................... OF .....................................................................................
dw
%untifirFa#.r of Tom0l aurr
THIS IS TO C RTI Y, Pat the Individual Sewage Disposal System constructed ( ) or Repaired (�
by ---------------------- ------------------------- �e ..........................................
...------------------------------•.
�` -----
i ----------------------------------------------------------
tailed in accordance with the provisions of TITLE j of T State Sanitary Code described in the
has been P
application for Disposal Works Construction Permit No_____ ___ ______ �/ __ dated_! -F�' z--------•-•
�s . . - - �-
THE ISSUANCE OF THIS CERTIFICATE SHAL NOT BE CONSTRUE® AS A G RA EE THAT THE
SYSTEM WILL FUNCTION SATISFACTORY.
DATE-------------------------------------------------------------------------------- Inspector