HomeMy WebLinkAboutApp-Permit-ComplianceWA
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THE COMMONWEALTH OF MASSACHUSETTS
BOARD PF HEALTH
i
..........1 ........... OF....... _,4a_) ho%_)_7'#-----------------------------------------
Appliration for Di-4paii al ?forks Tomlrnrfion frrmit
Application is hereby made for a Permit to Construct (K) or Repair ( ) an Individual Sewage Disposal
System at:
........
Location - ddr ss No.
..�..
Addr s
Installer Address
Type of Building„— Size Lot ... 4,/�b...... Sq. feet
Dwelling —No. of Bedrooms ........ . l wo....................Expansion Attic Garbage Grinder
Other — Type of Building .......... ............. No. of persons ----------- -------------- Showers (---) — Cafeteria (�)
Otherfixtures------------------------------------------------------------------------------------------------------- ......................................
Design Flow ..--...�........................gallons per person per day. Total daily flow -___•-_-- C2-75.0 P•........ _..gallons.
Septic Tank — Liquid capacit3M_ __OD_gallons Length ................ Width ................ Diameter ---------------- Depth ................
Disposal Trench — No . .................... Width____ �,__------------ Total Length ............ . Total leaching area... ................. sq. ft.
�D1i %.----•--- . ?�7_ ft.
Seepage Pit No_____ _ __ ________ Diameter... __ Depth below inlet__...�t�..__....... Total leaching area. .._sq.
Other Distribution box Dosing to k
Percolation Test Results Performed by --------
-`L...............�..._._.__...._._. Date ..... ._.__�___ __.
Test Pit No. 1 ----- ..._..minutes per inch Depth of Test Pi er-_-•-- Depth to ground ater...WZF, .
Test Pit No. 2................minutes per inch Depth of Test Pit .................... Depth to ground water ........................
------------------------------------------ ------------------------------------------------------------------------------------------------------------------------------------------------------------
Nature of Repairs or Alterations — Answer when applicable.______"................................................................................
Agreement:
The undersigned agrees to install the aforedescribed Individual Sewage Disposal System in accordance with
therovisions of'ITL
p of the State Sanitary Code —The undersigned further agrees not to place the system in
operation until a Certificate of Compliance has be n issued by the board of healt
Si ned- -� _ x/11 _ ..
' Da
Application Approved By.. - -•---•--A---•. �-- ....-•-----• .. .......................
----------------- ----- -----------
Date
Application Disapproved for the following reasons: ....................................
Date
PermitNo---------------------------------------------------------
Issued.........................
Date
THE COMMONWEALTH OF MASSACHUSETTS
BOARD O�_2,
HEALTH
......... w �.........OF.............M.00�'.................................
Trrfifiratr oompt
THIS Tj ERTIFY, That the Individual Sewage Disposal System constructed (}< or Repaired ( )
byE f:e�--�W-�------------------------------ -------------------------•-------------•--•------------------.........................................
/ Installer
4j__;� .... /
14
has been installed in accordance with the provisions of TITL:j of The State Sanitary ode as described in the
application for Disposal Works Construction Permit No. �2'- . � [ ? ........ dated ------------------_-----_ ..................
THE ISSUANCE OF THIS CERTIFICATE SHALL NOT BE TRITE® AS A GUARANTEE AT THE
SYSTEM WILL FUN TIO SATISFACTORY. f`
DATE .............. `Inspecfat �_ .