HomeMy WebLinkAboutApp-Permit-ComplianceFrcu...._e 9--d d......
THE COMMONWEALTH OF MASSACHUSETTS
BOARD OF HEALTH
................................................................................
Apphrttiion for Biu uiiat Workti TiauBtinr#inn Vvimi#
Application is hereby made for a Permit to Construct
System at ZIA
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..............
Instaner
Type of Building Size Lot ............................ Sq. feet
Dwelling —No. of Bedrooms.. .......................... ... Expansion Attic ( ) Garbage Grinder ( )
Other—Type of Building ............................ No, of persons.... ........................ Showers ( ) — Cafeteria ( )
Other fixtur.......... __........................... ___....................... ............. .------ .........
....
Design Flow ............. ...............gallons per person per day. Total daily flow ..................... ............gallons.
Septic Tank — Liquid capacity ............ gallons Length---.. .......... Width ................ Diameter ....... Depth................
Disposal Trench — No. _.................. Width .... r.......... Total Length .... ...,4.......... Total leaching area ... .......__... sq. ft.
Seepage Pit No ............./..... Diametenl e. ._....."Depth below inlet__...ICT.......... Total leaching area... .y.. _. 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 ............ ..---- ......
) or Repair (✓) an Individual Sewage Disposal
Z 07- A y M /1)� 5,3
Description of
of
The undersigned agrees to install the afor
the provisions of TITLE 5 of the State Sanitary
operation until a Certificate of Compliance has be
Application Approved
Application Disapproved for the following reasons:
Permit No.....A�a/.......................
bed Individual Sjhage Disposal System in accordance with
— The undersi ed other agrees not to place the system in
ted by t e b • •d o iealth.
........ .... ............................ 7..17....
Date
>r
Date
Date
Issued ........... . :..... S ./......
Date
THE COMMONWEALTH OF MASSACHUSETTS
_ BOARD , F/ HEAL'
........�.. %U'.� :.............. OF.....('///.1.l r.(t ."!/
of Gantplinurf
;wage Disposal System constructed ( ) or Repaired (4
has been installed in accordance with the provisions of TFLE 5 of The State Sanity Code as described in the
TF
LE
for Disposal Works Construction Permit Nair..z...dated..,..:...............
THE ISSUANCE OF THIS CERTIFICATE SHALL NOT BE CONSTRUED AS A GUARANTEE THAT THE
SYSTEM WILL FUNCTION SATISFACTORY. �
DATE ....... r� a�.Sr.:. YY........................................Inspector..��/ .cc a c <—may ............