HomeMy WebLinkAboutApp-Permit-Compliance No ... '..._...... Fss .. 1 !.'^cl
THE COMMONWEALTH OF MASSACHUSETTS
BOARD OF HEALTH
OF ytmintikza
Ap liratinn fur Disposal ►,r;urkn (unitrurtiun Eirmit
Pf
Application is hereby made for a Permit to Construct ( ) or Repair ( +✓ an Individual Sewage Disposal
System 3'7.: L _ ,,.. a. :::�. _....._...._.
'- ' &ocation�Address~lTor Lot No.
��ea!!``'
a&A,
fner
Address1-4
......_.
Install I Address
Type of Building Size Lot. Sq. feet
Dwelling—No. of Bedrooms Expansion Attic ( ) Garbage Grinder ( )
p., Other—Type of Building No. of persons Showers ( ) — Cafeteria ( )
Other fixtures
W Design Flow gallons per person per day. Total daily flow gallons.
Septic Tank—Liquid capacity gallons Length Width Diameter Depth
z• 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 ( )
Percolation Test Results Performed by. Date
Test Pit No. 1 minutes per inch Depth of Test Pit Depth to ground water
(T, Test Pit No. 2 minutes per inch Depth of Test Pit Depth to ground water
O Description of Soil
Nature of Repairs o Iterations—Ans er when appl•cabl ...., .O 6
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 has b issued by t b of health.
Signed.. g—4'SI?
Date
Application Approved By
Date
Application Disapproved for the following reasons:
Date
Permit No Issued_
Date
THE COMMONWEALTH OF MASSACHUSETTS
BOARD OF HEALTH
OF
ftrr#if ira of faungtliuna
THIS IS T=IFY, T the :vidual Sewage Disposal System constructed ( ) or Repaired (
7 •
gadtd -e.
• O Installer
at
has been installed in accordance with the pr v. ons of TITLE 5 6f The State Sanitary Code as described in the
application for Disposal Works Construction Permit No dated
THE ISSUANCE OF THIS CERTIFICATE SHALL NOT BE CONSTRUED AS A GUARANTEE THAT THE
SYSTEM WILL FUNCTION SATISFACTORY.
DATE Inspector
THE COMMONWEALTH OF MASSACHUSETTS
BOARD OF HEALTH
OF
No FEE
Biu u 4 1 rr urku .unu Lytton 1rrntit
Permission is hereby granted.... ` / a .� cy� �
to Construct ( ) or air ( an Indi id Sewage D's+osal stem
at No ... Q.e( �l j.... z.
i Street
as shown on the application for Disposal Works Construction Permit No Dated
DATE Board of Health