HomeMy WebLinkAboutApp-Permit-ComplianceOKI 117 Fz
THE COMMONWEALTH OF MASSACHUSETTS
BOARD OF HEALTH
................OF.......
-------OF....... 4 .......................................
Appliration for Disposal Works Tonstrurtion 1hrmit
Application is hereby made for a Permit to Construct or Repair (4--yan Individual Sewage Disposal
System at: A
---------------------------- - ------------------- ................. . ..
Location - Address .... . Lot No.
..... . . . ............................................................. ......................................... . ......................... . . . .
er Address
..................................................................................................
Installer Address
Type of Building Size Lot ............................. Sq. feet
Dwellingo. of Bedrooms ............................................Expansion Attic Garbage Grinder'(,
Other — Type of Building ............................ No. of persons.....__._._.___..__.____.... Showers Cafeteria
Other fixtures .----•----------------------------------------
WDesign 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.
Z Other Distribution box ( ) Dosing tank ( )
1.4 Percolation Test Results Performed by .......................................................................... Date ........................................
1.4
Test Pit No. I ................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 ........................
0
Description of Soil
.................................................................................................................................. ----------
--------------- * ----------------------------------------- * --------- * ------------------------------------------------------------------------------- * ------ --------------------------------------------------
---------- - U Nature of Repairs or Alterations — Answer when applicable ....... . X) ...........................................
.................................................................. w ............................................. . ..... ... ........................................................
Agreement:
The undersigned agrees to install the aforedescribed Individual Sewage Disposal System in accordance with
the provisions of TITLE. LEj 5 of the State Sanitary Code — The undersigned further agrees not to place the system in
operation until a Certificate of Compliance has bD �ilssue(i 'DW ythe,4oard of health.
. ............. ....
Signed.
Date
ApplicationApproved BY-... ........... ................................................................... ......... ------
ate
Application Disapproved for the following reasons: --------------------------------------------------------------------------------- -------------------
ISSUedj�Z Date
. __a
PermitNo. Zij/i ................................. . . . ........ .
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THE COMMONWEALTH OF MASSACHUSETTS
BOARD OF HEALTH
....... ............. OF ...... ........................................
Trrfif iratr of Tomplianu
,=49J�7,61 CERTIFY, That the Individual Sewage Disposal System constructed or Repaired (Z-)--
....... ................................................................. a ........ . ..........
by ..... . V.A ... ........ )
gV ---------- Z��,5r -- - ----- ----- - --------------------------------------------------------------------------
at .... �AV ..... �3
has been installed in accordance with the provisions of TITM 5 of The State Sanitaryod 5 describ-A in the
1 F�
application for Disposal Works Construction Permit No.-T77-.1a ......................... dated_... .... ------ R.! .............
THE ISSUANCE OF THIS CERTIFICATE SHALL NOT BE CONSTRUED As 4AAG RANTEE THAT THE
I�LL_F CTION SATISFACTORY.
SYST
..... -Inspector,----. ---- ---- ------ - ------- -- ------------------
DAT;7 ........... ...................