HomeMy WebLinkAboutApp-Permit-ComplianceNo.- ./2...-.. - Fss,�. ✓...
THE COMMONWEALTH OF MASSACHUSETTS
BOARD OF HEALTH
.......................... .................OF./i49M.WF! ..............................................
Applirtttiun for Disposal Works TonVrrmit
Application is hereby made for a Permit to Construct
Systema at :
...... ...... .K�.. �.p.�t ..... a .................................
Location •Address
-- ..------.a_- - - ,I ...d..�...............................................
Owner
Type of Building
Dwelling —No. of
Other —Type of F
Other fixt
Design Flow ....................
Septic Tank — Liquid c
Disposal Trench — No.
Seepage Pit No ............ .
Other Distribution box I
Percolation Test Resul s
Test Pit No. 1.......
Test Pit No. 2........
Installer
or Repair an Individual Sewage Disposal
-.. or. Lot No.
..----•-----•-•-•--------------•---................_.....
' 1
Address
� w...............-----•-----------------•----..................
ddress
Size Lot ............................ Sq. feet
ins...........................................Expansion Attic ( ) Garbage Grinder ( )
.......................... No. of persons ............................ Showers ( ) — Cafeteria ( )
.........................................................
allons per person per day. Total daily flow........:...................................gallons.
--- ------g Ions Length ................ Width ................ Diameter................ Depth ................
Wid .................... Total Length .................... Total leaching area .................... sq. ft.
a eter.•..... ............ Depth below inlet .................... Total leaching area .................. sq. ft.
D ing tank ( )
ormedby--•-•-•-----•-••-••---•-----•-------•••-----•-._...--•-----•---••-----•--- Date........................................
utes per inch Depth of Test Pit .................... Depth to ground water ........................
antes per inch Depth of Test Pit .................... Depth to ground water ........................
Descriptionof Soil --------------------------------------------------------------------
-----------------------------------•---•--------•-----•---•----•------•-•--.---------.............---•----------•-•---------.....•• ---------------•---------------•-------
Nature of Repairs or Alterations — Answer when ap lica.ble..,l_ ? �� __..`� __ ht_�s.-. ..•.....•••.
Agreement:
The undersigned agrees to install the aforedescribed Individual Sewage Disposal System in accordance with
the provisions of 'AI T%.L 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.
Signd. ......... ------...lS-------................................................... 2 Ll -
Application Approved By ........ ( ................................................... D .
Application Disapproved for the following re ons- ---------------------•---------.._......--------------------....---------.......-------•-•-------•----••--...-
.... ----•---- — --------------- -..... Date
-
PermitNo ....................................................... . Issued..!= ( ---- -/- %........
Date
THE COMMONWEALTH OF MASSACHUSETTS
BOARD OF HEALTH
..........................................�lN OF.. l'A..6Zli').�J.U. ..,
Trrtif irtt of T o mplittnrr
THIS IS TP�CERTIFY, That he Individual Sewage Disposal System constructed ( ) or Repaired ( )
by (V��
-Installer
at------- - i01� -� I dt...... ................................................................
has been installed in accordance with the provisions of TITLE 5 of The State Sanitary Code as described in the
application for Disposal Works Construction Permit No .... (:2Q_- ----------- dated __..____�J.�...2�._� ��!.....
THE ISSUANCE OF THIS CERTIFICATE SHALL NOT BE ONSTRURD�A GUARANTEE THAT THE
SYSTEM 1.L FU�ICTIQt� SAT 1 AC}TORY. ,� )),