HomeMy WebLinkAboutApp-Permit-ComplianceNo. .�`---
THE COMMONWEALTH OF MASSACHUSETTS
BOARD F -HEALTH
OF....... ................................................. ....
Appliration for Disposal Works Tonstrurtion rnmit
Application is hereby made for a Permit to Construct ( ) or Repair (tJ)/an Individual Sewage Disposal
syste�, at........ qO-
- ------ ...._._.._.
L� �� or Lot No.
............y�....._.._........................ ....•---- ..................•....... ........ —`----- A -. ........ - ...........................
L� Address
............ . ................ ..^ `" "".'1�: !..^ ....... .._......._.._..
Installer Address
Type of Building Size Lot ............................Sq. feet
Dwelling — No. of Bedroo s...........................................Expansion Attic ( ) Garbage Grinder ( )
Other — Type of Buildin ............. ............ No. of persons ............................ Showers ( ) — Cafeteria ( )
Otherfixtures ...............=---..................... ------••••-•--•---••---------•............---
Design Flow..........................................g ns per p son per day. Total daily flow ............................................ gallons.
Septic Tank — Liquid' capa ty......._.___g ength.............:.. Width ................ Diameter ................ Depth ................
Disposal Trench — No .................... W' th...... ............. Total Length .................... Total leaching area .................... sq. ft.
Seepage Pit No .................... Diamete ............... .... Depth below inlet .................... Total leaching area .................. sq. ft.
Other Distribution box ( Dosing tank ( )
Percolation Test Results Pe rmed by .......................................................................... Date ........................................
Test Pit No. 1................m nutes 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 .....................................................................................................................................
......:...
Nature of Repairs or Alterations —Answer when applicable__ ____________________'a)" 'l _..... _._-----., _._____ � �``� s c/ `
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Agreement:
The undersigned agrees to install the aforedescribed Individual Sewage Disposal System in accordance with
the provisions of T I T M 5 of the State Sanitary Code — The undersigned further agrees not to place the system in
operation until a Certificate of CompAha issued by the board of alth.teApplication Approved By---•-- --................................................
-•.....................:
Application Disapproved for
.........................•---•-•---��y.`.��----•---•--•---------------....-----•-•--------...._................---ISSUCCL---- -- -•I4! F._-----.Date•----•
Permit No.__ �p
Date
THE COMMONWEALTH OF MASSACHUSETTS
BOARD OF HEALTH
.......................................... O F... ...:!..�............................................................
Trrtif a r laf T-nutpliatty
THIS IS TO CERT�I-Fy, That the Wiviptal Sewage Disposal System constructed ( ) or Repaired
.. inscauer 4
.................................... .......
has been installed in accordance with theovisioils of T .T of The State Sa.nitar ode d r' d in the
app, ication for Disposal Works Construction Permit No._ �s ................... dated_ ....__.._.__...
THE ;SSUANCE OF THIS CERTIFICATE SHALL NOT BE CONSTRUE® AS A /A E THAT THE
SYSTE LFUNCTTIION SATISFACTORY.�--
DATE....L_��_12. _..:__:.... Inspectors.: 4�� J -- --