HomeMy WebLinkAboutApp-Permit-Compliance2p
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THE COMMONWEALTH OF MASSACHUSETTS
BOAR OF HEALTH
OF.� g Dt rH
Appliratiuu for Bi, poral Works Toulitrurtiou 11amit
Application is hereby made for a Permit to Construct
or Repair an Individual Sewage Disposal
M1�P- 121
Type of Building e y Size Lot ... ......................... Jq. feet
Dwelling —No. of Bedrooms..........:`.............................Expansion Attic ( ) - Garbage Grinder ( )
Other — Type of Building ............................ No. of persons............................ Showers (m - ) - Cafeteria ( )
Otherfixtures.-----------------------------------------------------..................--......-------------------------...................................
Design Flow......... (_2.........................gallons per person per; dax. Total dais flow.....,? w Vi=i....... gal
. .................... ions.
Septic Tank—Liquid capacity.)D.OZ)gallons Length.... Width...°.t` .'14... Diameter ................ Depth ................
Disposal Trench — No Width Total Length Total leaching area ..............sq. ft.
Seepage Pit No ... 100AS° iameter..... r ® .. Depth below inlet to Total leaching area .............sq. ft.
Other Distribution box (1,-)" Dosing tank "( ") r 7 o- r
Percolation Test Result Performed by.5 3t�.i....... �1 *?. �'�" `u: n............ Date t:.... F ................
Test Pit No. ]...........minutes per inch Depth of Test Pit .....I. ::.'Depth to groundwater ......kj.' ?..........
Test Pit No. 2....._a�?..minutes per inch Depth of Xest Pit..... f. 2......... Depth to ground water .... _1: Fl.........
Description of
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 TITLis 5 of the State Sanitary Code — The undersigned further agrees not to place the system in
operation until a Certificate of Compliance has been urged by t(te board, of health,, /
Application Approved_.1--A
Application Disapproved for the following reasons:
Permit No.�.1,�.., .`./a .........................
Date
THE COMMONWEALTH OF MASSACHUSETTS
__......_.m,
BOARD OF HEALTH
/ f)
Tertifiratle of Tomixlittnrr
IS IS TQ CERTIFY, That the Individual Sewage Disposal System constructed ( ) or Repaired (k )
Installer
has been installed in accordance with the provisions of T, `` of The State Sanita;y ode a�'descnbed i the
application for Disposal Works Construction Permit No..f`_._.`...4%k..................... dated -i!
s 2P. 1 ...7J ...
THE ISSUANCE OF THIS CERTIFICATE SHALL NOT BE CONSTRUED AS A (GUARANTEE THAT THE
SYSTEM WILL FUNCTION SATISFACTORY.
DATE.............................:....... ........................ Inspector .....................................................................................