HomeMy WebLinkAboutApp-Permit-ComplianceTHE COMMONWEALTH OF MASSACHUSETTS
BOARD OF HEALTH
.......... ............ ............... .... .OFY .................................
Fins/ 5 _......._
Appl ration for Disposal Work, Cfnnstrnrtion Ilermit
Application is hereby made for a Permit to Construct ( ) or Repair (M -'an Individual Sewage Disposal
System at:
_.I.._...1—�i�....N...r®.::cf� .................................................................................................................._.............
Owner
Installer
Type of Building
Dwelling—No. of Bedroo
Other —Type of Buildin
Other fixtures .....
Design Flow .........................
Septic Tank — Liquid cap c
Disposal Trench — No- _ ---..
Seepage Pit No... ........... ..
Other Distribution box )
Percolation Test Result
Test Pit No. I ..............
Test Pit No. 2 ...............
Description of
or Lot No.
(
..........................................
.............. ..........................................
Address
Size Lot ............................ Sq. feet
.........Expansion Attic ( ) Garbage Grinder ( )
of persons ............................ Showers ( ) — Cafeteria ( )
er person per day. Total daily flow............................................gallons.
Length ................ Width ..... -----...... Diameter................ Depth ................
........... Total Length .................... Total leaching area ............... ..... sq. ft.
... Depth below inlet .................... Total leaching area .................. sq. ft.
tank ( )
per inch Depth of Test Pit .................... Depth to ground water
per inch Depth of Test Pit .................... Depth to ground water,
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 5 of the State Sanitary Code — The undersigned further agrees not to place the system in
operation until a Certificate of Compliance has been issued
dbby!the board of health. ��y�
S' ned. _-Lit i ce___ ........ ....... �°z.. ::.s!.. �....
......... - ............... .........
Application Approved By...1 .......... ......................-------------.................................
'{' baa<.............
Application Disapproved for the forlbwint reasons:
Permit No........ _V ............
Daze
THE COMMONWEALTH OF MASSACHUSETTS
BOARD OF HEALTH
OF ...':,.e.'::JUD`...elt:.Cf:%°.n.�......................................
(grr#ifirate of Tomplinnre
THIS IS TO CERTIFY, That the ndividu 1 Sewage Disposal S- stem constructed or Repaired r
has been installed in accordance with the provisions of TITL�_p5f The State Sanitary Code as described in the
application for Disposal Works Construction Permit No ...... ;.....:......... dated........�.i::...�.. _1.7 ...............
THE ISSUANCE OF THIS CERTIFICATE SHALL NOT BE CONSTRUED AS A GUARANTEE THAT THE
SYSTEM WILL FUNCTION SATISFACTORY
' g . P, 1), f 'DATE. ,
......................... Ins ector .
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