HomeMy WebLinkAboutApp-Permit-Compliancer 9Vf.✓....� --- Fan .... 1i.�7.'..............
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THE COMMONWEALTH OF MASSACHUSETTS
BOARD OF HEALTH
........................................ OF .......... ...................... ............... ................ ......... I.................
Appliration for M.4p stt1 Worko Tonotrnrtion Vantit
Application is hereby made for a Permit to Construct
System at: i
....�-2.
Locat' Add ss f
/ /
.......................................... ............. -----. -- .....
) or Repair (A an Individual Sewage Disposal
or Lot No.
Address
nstaller 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 .............. ____ ...... '-"'-"............ ....... "...._........................... ____ ............ ....... ____ ....... ..... "•
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. it.
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. 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........................
Descriptionof Soil.......""'-""""""""' ..................................... -'--"""""""""'-'-""""............................ ..................................
Nature of Repairs or Alterations — Answer when
Agreement:
The undersigned agrees to install the aforedescribed Individual Sewage Disposal System in accordance with
the provisions of TITLE S of the State Sanitary Code — The undersigned further agrees not to place the system in
operation until a Certificate of Compliance has beA issued by the boal:yLpf liyAjth//.
Application Approved By.;�K_.c
Application Disapproved for the
�DD
Data
Permit No..... ....:.. .....................•.......
THE COMMONWEALTH OF MASSACHUSETTS
BOARD OF HEALTH
............I ............................. OF .......................................... ........................... .......
Trrtifirat>' of Tautplittnrr
THIS IS TO CERTIFY, That the Individual Sewage Disposal System constructed ( ) or Repaired (u )
i
has been installed in accordance with the provisions of TITLE 5 of The State Sanitary Code as described in the
application for Disposal Works Construction Permit No..%-.: ...1 ....::............... dated......',.:'.w'.Z........ ...........
...,
THE ISSUANCE OF THIS CERTIFICATE SHALL NOT BE CONSTRUED AS A GUARANTEE THAT THE
SYSTEM WILL FUNCTION SATISFACTORY.
Inspector-"""""""""'.....__..-'-'-""...................................""'...