HomeMy WebLinkAboutApp-Permit-ComplianceTHE COMMONWEALTH OF MASSACHUSETTS
BOARD OF HEALTH
........�...�. W V�...... OF ......... -j. ..14 :P !M:!!'t........................................
Appliration for Disposal Warks Tonutrnrtion t1ermit
Application is bereby made for a Permit to Construct ( ) or Repair ( k4 an Individual Sewage Disposal
tsi System at: PO P D :5 EN b
Location - Address orLotNo.
.................................... .............. .r�.uv--......---------............__.... __ ...
a
Address
...................... _—
cr........................................•
Installer Address
Type of Building Size Lot ............................ Sq. feet
aDwelling — No. of Bedrooms...... .................................Expansion Attic ( ) Garbage Grinder ( )
p, Other — Type of Building ............................ No. of persons............................ Showers ( ) — Cafeteria ( )
Otherfixtures ... .......... _... ...................................................................... ..............................................................
W Design Flow..... ..ice..........................gallons per person per day. Total daily flow...... t�3JC:?..................... gallons.
W Septic Tank — Liquid capacity}�.gallons Length .... Qi ._... Width... (....... Diameter ................ Depth ................
Disposal Trench — No_ j .............. Width.. ...... If Total Length.....a V.'... Total leaching area ...................sq. ft.
3 Seepage Pit No ..................... Diameter................... Depth below inlet.................... Total leaching area .................. sq. ft.
Z Other Distribution box ( ) Dosing tank ( )
aPercolation Test Results Performed by ............. ............................................. .......... ...... Date .......................................
1 Test Pit No. I................minutes per inch Depth of Test Pit.................... Depth to ground water........................
W Test Pit No. 2................minutes per inch Depth of Test Pit.................... Depth to ground water........................
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ODescription of Soil ..........................................................................................
W
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U Nature of Repairs or Altera ions—Answer w n applicable._. ± � ...... ((a F.. L.`.Z.:k3µ_
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 Certifi
Application Approved
Application Disapprove
Permit No. 4?...
Q Grp f_�� I lf....: --� .�•7 .................................... Issu ..........
t% � Date
THE COMMONWEALTH OF MASSACHUSETTS
BOARD OF HEALTH
..... $ ° .5:::..: f' ..........OF .; s:.,. .....i.:: ....................................
Trrtifiratp of Toutpliam
THIS IS_TO CERTIFY,. That the Individual Sewage Disposal System constructed ( ) or Repaired ( )
by.........................4. t:`.
-........................................
Installer
has been installed in accordance with the provisions of T T { The State Sanitary Geode as dperttled kintete
application for Disposal Works Construction Permit No.. k f ...... ...... dated l• t .. ti
THE ISSUANCE OF THIS CERTIFICATE SHALL NOT BE CONSTRUED ASA GUARANTEE THAT THE
SYSTEM WILL FUNCTION SATISFACTORY.
DATE �� z. ��.....?.A . .'.. w
.................. Inspector. ... .......
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