HomeMy WebLinkAboutApp-Permit-ComplianceFmm ...."...............
THE COMMONWEALTH OF MASSACHUSETTS
BOARD OF HEALTH
. _........... _....._.
...OF.... .'°-- ----------------------------------------------------------- - -
.................
, pplirFation for Disposal ork�i Tontrnrtion Famit
Application is hereby made for a Permit to Construct ( ) or Repair ( an Individual Sewage Disposal
System at: L O� D �s MA 14
.....----•------•------'-•--
ss. y/ )or Lot Lo on -.Address
; ...........................................................
.............�Address
wner�
-----....--
Installer dress
Type of Building
Dwelling — No. of Bedrooms ----------------------
Other — Type of Building --------------- --------
Other fixtures ------------- ---------------
Design Flow -----------------------------------••--llo
ns p
Septic Tank — Liquid capacity ----- ---- ::ns pllons
Disposal Trench — No ............... ... idth-.....
Seepage Pit No --------------------- D' met r..--__....--.-..
Other Distribution box ( ) Dosing
Percolation Test Results e ormed by......
Test Pit No. l ................ nutes per inch
Test Pit No. 2 ----------------minutes per inch
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Description of Soil ------------------------------------------
Size Lot ----------------------------Sq. feet
...--.Expansion Attic ( ) Garbage Grinder ( )
E persons ............................ Showers ( ) — Cafeteria ( )
....-------
;r pers n -p-- e--
er day----T---o--t-a--I daily flow.._.._. gallons.
gth-•--•••--------- Width---------•-•--.. Diameter---------------- Depth----------------
........... Total Length .................... Total leaching area -------------------- sq. ft.
.-. Depth below inlet .................... Total leaching area .................. sq. ft.
-----•-•---------------- Date ----------------------------------------
De th of Test Pit .................... Depth to ground water ------------------------
Depth of Test Pit .................... Depth to ground water..--.---................
............................................. ----- -----------•------------..........-----...---------....---------------------------------------------•-------•---
--.......... ------------------- ----- -------------- ----- ------- -------------- -------- ----------- ----------------------------
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Nature of Repa>rs or Alterations — Answer when applicable/!55 ? .' -- -------------------
---------•------------•----•-•-----...•----------•----------------•--••-- -•---------------•------•---•-••---------------------------------•--•--------------
Agreement :
The undersigned agrees to install the aforedescribed Individual Sewage Disposal System in accordance with
the provisions of 'TTLE 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 b the board of health.
Signede ...... 7� •-------•-...--------•-------•--- / .'.... te..
Application Approved By -------------------------------------------
Application Disapproved for the following reasons- ----------------- ------
Permit N
Issued- ------------------------
Date
THE COMMONWEALTH OF MASSACHUSETTS
BOARD OF HEALTH
Date
--------------------------------------
Date
IL.... OF. ..............................................................
(grrtifirab of Tontplittnrr
THIS IS
T TIFY That e Ind' 'dual Sewage Disposal System constructed ( ) or Repaired (�
by ���6-� •-------�•.=-......•----------•.....-�-....-------- -------•-----------•-----
nstall�r
at m G--•---�...............
----------------�'' ---------------------
has been installed in accordance with the provisions of T 7 �' 5 of The State Sanitary �C�de s des ibed in the
application for Disposal Works Construction Permit �'o._-. -- -."_ dated - -,_/._Q..----- -
J�_
THE ISSUANCE OF THIS CERTIFICATE SHA [+SOT BE CONSTRUED ASA ARA TEE T AT THE
SYSTEM WILL FUNCTION SATISFACTORY.
r
DATI?----.... ------- ----------------------------------- Inspector ....................................................................................