HomeMy WebLinkAboutApp-Permit-Compliance�W
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f ` THE COMMONWEALTH OF MASSACHUSETTS
BOARD OF HEALTH
e. OF
� 112/.r%� ,vr �f-._......---•-------------------------
2q Appliration for Iliopos al Works Tonotr t' rrutit
Application is hereby made for a Permit to Construct or Repair ) Individual Sew
a a Disposal
Systemat:Z) c !!.. -_.. ....-- ?------. .•--------•------••--•....------•.
. Locatio - ddres or Lot No.
...................... _•-
42 .....
Address
Installer Address
Type of Building Size Lot ............................ Sq. feet
Dwelling —No. of Bedrooms --------------------------------------------Expansion Attic ( ) Garbage Grinder ( )
Other — Type of Building ............................ No. of persons ............................ Showers ( ) — Cafeteria ( )
Otherfixtures------------------------------------------------•------•-----------------••--------------------------------------------------------------------------
Design Flow............................................gallons per person per day. Total daily flow ............................................ gallons.
Septic Tank—Liquid capacity ............ gallons Length ................ Width ................ Diameter ......... ....... Depth ................
Disposal Trench — No ..................... Width .................... Total Length .................... Total leaching area .................... sq. ft,
Seepage Pit No ............._-____ Diameter .................... Depth below inlet .................... Total leaching area .................. 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 ........................
Description of Soil...
- ------ --psi -- or ---lt r -io s ---- -- n --- � .../ �---- ------------------------------
Native of Repairs or Alterations —Answer when a licable_._ __,l_ST/-� �.______./0-01 7--__I _____________________
,greement :
The undersigned agrees to install the aforedescribed Individual Sewage Disposal System in accordance with
the provisions of TITIE 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 by the board of health.
Signed.
-` -
i -----
Application A roved B ----------•-------------
PP Y - . -- o T----- Date
Application Disapproved for tW 9 j0ifivsQi frkMS: ----•-------•-•------------------•---------------------•--------------------------------------------------------
------------------------•--------....---••-•------------------•-----------------------------------•-••••.---•-----._.....------....-------------------------------------------------------•-------------
Date
PermitNo --------------------------------------------------------- Issued -----------•-------------------------------•--------._..
Date
THE COMMONWEALTH OF MASSACHUSETTS
BOARD OF HEALTH
� ....... OF ........ .. l/ r'% ��� ...............................
Trxiifirab of Tootpfianre
THIS S TQ/YER IFY, That the Individual Sewage Disposal System constructed ( ) or Repaired
byr .Clf....__.. .....................•---f----.......---------------------...--------------------------------------------......----...............--•-----------------
i Installer
has been installed in accordance with the provisions of TITLF 5 of The State Sanitary Code as de•cribed ' the
.__ ..
application for Disposal Works Construction Permit No_ ,�.......... dated_. ._:.cam -t,_ ....... -a-----------
THE ISSUANCE OF THIS CERTIFICATE SHALT. NOT BE CONSTRUE® AS A GUARANTEE THAT THE
SYSTEM WILL FUNCTION SATISFACTORY.
TIATF
Tre —Irf