HomeMy WebLinkAboutApp-Permit- Compliance' , • , 5�e > -P" IV. "Tl-
,( Ficis 0y
THE COMMONWEALTH OF MASSACHUSETTS
BOARD 9F HEALTH
,Rpphrtt#inn for Dhipnottl lgorko Tonotrnrtfoit Permit
Agreement:
The undersigned agrees to install the aforedescribed Individual Sewage Disposal System in accordance with
the provisions of TITU S of the State Sanitary Code — The undersigned further agrees not to place the system in
operation until a Certificate of Compliance has been issued by the board of health,
Application Approved By--.' C%4`.?2
Application Disapproved for the following
Permit No..Q.u. aZ-K..................................
Date
THE COMMONWEALTH OF MASSACHUSETTS
Date
Date
BOARD OF HEALTH
........................... OF_ a'.. d.../))".t.......................................................
Ta ifirtttt of Toutplittnrr
S TO CERTIFY, That the Individual Sewage Disposal System constructed O6) or Repaired ( )
%' . j qq ! Installer
k f.. err.r . Nr"il F.�.. nd.-�n �, .o a'rf
has been installed in accordance with the provisions of TITLE,, $rof The State Sanitary,Co4c as d cribed•in the
application for Disposal Works Construction Permit No_ .. �.0. ....................... dated, �C''..`.. :..:_:::,;_ f ........
THE ISSUANCE OF THIS CERTIFICATE SHALL NOT BE CONSTRUED AS,A'GUARANTEE THAT THE
SYSTEM' WILL FUNCTION SATISFACTORY. `
DATE.. . z ... ' Inspector...:_r
Application is hereby made for a Permit to Construct (X) or Repair (
) an Individual Sewage Disposal
system at: L) v
� es:�...�c��.......W:....I>nQ 4�.*.. ....... .lr.......................
i (o .........��:..... 5J�
,C
L tion - Address
or Lot No.
Owner
Address
pq
6
Installer
Type of BuildingSize
Bedrooms.....Attic (
Address
Lot ............................ Sq. feet
) Garbage Grinder ( )
aDwelling—No.
of .........................Expansion
p
Other — Type of Building ............................ No. of persons............................
Showers ( ) — Cafeteria ( )
Otherfixtures .................. -----..................................................................
.............................................................
��,ss��
Design Flow ........... sS.........................gallons per person per day. Total daily
flow ......... .��..................... gallons.
(_o.....
WSeptic
Tank —Liquid capacitylG?oRgallons .....
Diameter ................ Depth..
x
Disposal Trench — No. . ................... Width................... Total Length ....................
(
Total leaching area .......-c ..--...sq. ft.
3
Seepage Pit No ......... ....... .... Diameter.........(.C2..... Depth below inlet ....5n!........
Total leaching
Other Distribution box (7y Dosing tank ( )
Percolation Test Results Performed by......... ......... LQk ................
Test Pit No. I...�.�minutes per inch Depth of Test Pit...I./l .....
Date ...... ............................ ......
Depth to ground water.... .r ........
Test Pit No. 2................minutes per inch Depth of Test Pit....................
Depth to ground water........................
ODescription
..... . .. .......1-•--------------------------............................................................----..............................
of Soil. ............. -.. jPACu .................. ..................... ...........................
....................................................
UNature
of Repairs or Alterations — Answer when applicable..... ..........................................................................................
Agreement:
The undersigned agrees to install the aforedescribed Individual Sewage Disposal System in accordance with
the provisions of TITU S of the State Sanitary Code — The undersigned further agrees not to place the system in
operation until a Certificate of Compliance has been issued by the board of health,
Application Approved By--.' C%4`.?2
Application Disapproved for the following
Permit No..Q.u. aZ-K..................................
Date
THE COMMONWEALTH OF MASSACHUSETTS
Date
Date
BOARD OF HEALTH
........................... OF_ a'.. d.../))".t.......................................................
Ta ifirtttt of Toutplittnrr
S TO CERTIFY, That the Individual Sewage Disposal System constructed O6) or Repaired ( )
%' . j qq ! Installer
k f.. err.r . Nr"il F.�.. nd.-�n �, .o a'rf
has been installed in accordance with the provisions of TITLE,, $rof The State Sanitary,Co4c as d cribed•in the
application for Disposal Works Construction Permit No_ .. �.0. ....................... dated, �C''..`.. :..:_:::,;_ f ........
THE ISSUANCE OF THIS CERTIFICATE SHALL NOT BE CONSTRUED AS,A'GUARANTEE THAT THE
SYSTEM' WILL FUNCTION SATISFACTORY. `
DATE.. . z ... ' Inspector...:_r