HomeMy WebLinkAboutApp-Permit-ComplianceTHE COMMONWEALTH OF MASSACHUSETTS
9 BnO)ARD OF HEALTH
"Of[/ J....OF......... '0 ..001 %�...�,•..l--40C�/y ....................
Appliratiarn for Disposal Works Tonstrurtion ljrrmit
Application is hereby made for a Permit to Construct ( or Repair ( ) an Individual Sewage Disposal
System at •
%� 1r�......h��....._���. ....................................................... 1./
Lo ation Ad re �-- - Lot o.
0_>0
O er A dres
Installer Address
Type of Building Size Lot./.�_ _ __________Sq. feet
U Dwelling —No. of Bedrooms ............................................Expansion Attic ( ) Garbage Grinder ( )
`4 Other — T e of Building No. of persons ............................ Showers — Cafeteria
a' Other fix res
. .............. gallons per person r da . TotalViiyl�4_iameter
.................._
W Design Flow ............. g p p `gallo�WSeptic Tank—Liquid capacity, 41 �allons Length_& .�idth--- ................ Depth__7
x Disposal Trench — No ..................... Width-_ _..__ ._._._. Total Length ........... ...__._Total leaching area ... ...___......... sq. ft.
Seepage Pit No.","/ ........... D' n eter./V_._C,?._. Depth below inlet....-:, .. Total leaching area ... .sq. ft.
_-
Z Other Distribution box (Dosin tank ( )
Percolation Test Results Performed by _-100X./yZ.�. Z_v._iz#-�f Date...... 914- -4,%`---.
Test Pit No. 1................minutes per inch Depth of Test Pit .................... Depth to ground water ........................
t=, Test Pit No. 2................minutes per inch Depth of Test Pit .................... Depth to ground water ........................
` De aption of 50il....... ..... " _ _.......... ,
W•-••-----•-------•----------------------•----------••--------••---------•---•---•--- ----------------•---•---------•------•---•----•------------•----••--•---.....-•---•--------------------------------
UNature of Repairs or Alterations — Answer when applicable............................................•.•.........--........._........_...__..........__.
J........................................................................................................................................................................................................
Agreement:
i The undersigned agrees to install the aforedescribed Individual Sewage Disposal System in accordance with
f ` the provisions of TITLE 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.
Application Approved By
Application Disapproved for the following reasons: ..........................
--------------------------------
Date
r -
.........
Date
------------------------------------------------------------------------------------------------•------------•----.._._....--•----------------•-•-•---•••-----...--••--------..................
Date
PermitNo ......................................................... Issued --------------------------------------------------------
Date
THE COMMONWEALTH OF MASSACHUSETTS
BOARD OF
' . .HEALTH
/
....... ... OF..... .X �t�tf�!.. ..................
uprrtifiratr of (1 Outpliam
f
THIS ZS TO CERTIFY, That_1he_, ,ndividMk1 S�wage_Disposal System constructed ( or Repaired ( )
Uy............... YC^................ :............._..-------------------------------------------------------------
-N
----•--------_-----•-----•----•_-••--•________
J In�ta11 - c t /THAT
--- •----
has been installed in accordance with the provisions of TI�`I�'_ 5 State Sanitary C �as: in the
application for Disposal Works Construction Permit'o.//....................................... dated___._._..._.'a._..__..__......-_.....
THE ISSUANCE OE THIS CERTIFICATE SHALL NOT BE- STRUE® AS A GUARA THE
SYSTEM WILL FU���jTI//y/�N SATISFACTORY.