HomeMy WebLinkAboutApp-Permit-Compliance` rNo.... FE s ................
THE COMMONWEALTH OF MASSACHUSETTS
`•'BOARD//OF HEALTH
�OGV.tV ..-... 0 F........ .�CA4.M4.........................................
Appliration for Uhiposal Works Tonotrnrtion ramit
Application is hereby made for a Permit to Construct (t,,�/or Repair ( ) an Individual Sewage Disposal
System at.
L t n Address or Trot No.
•..... ........--- --- ------ ......• ---•"- .................... .................&Cddr;e ........
Owner------•----••--'••......•--•'-'�-.........-'•'•'•-----•'-------'--'-•'••'---•------.....-•---- •-------------------
aInstaller Address / ,
dType of Building Size Lot- .,_'...... Sq. feet
U Dwelling — No. of Bedroom. 4n .....................Expansion ttic ( ) Garbage Grinder ( )
Other — T e of Building
711__.._...
__.._... No. of persons--••--••• Showers — Cafeteria
Q' Other fixtures -------------------------•-. _
Design Flow._____=_..o . .......................gallons per person per day. Total daily flow__._..._ ... e s�-_ .:c.....gallons.
W ice
WSeptic Tank — Liquid capacity/P.&)_.gallons Length .. %.._... Width.'iKA. Diameter ................ Depth___,15/!�..__
x Disposal Trench — No ____________________ Width .................... Total Length ................ ._ Total leaching area. -------------sq. ft.
Seepage Pit No_________________ Diameter_'....... Depth below inlet _ .....�........ Total leaching area`e4--sq. ft.
Z Other Distribution box ( ) Dosing a ) �Depth
Percolation Test Results Performed by_ __ _ __________•- Date....4, .4C,/fTest Pit No. 1..._..minutesperinch Depth of Test Pit..l..._.o ground water ... �..............
Test Pit No. 2................minutes per inch Depth of Test Pit .................... Depth to ground water ........................
---------------------/j-------....
----zy--•--•--•-••�•----------•-----•-------'--...---••'----.........................................................
Description of Soil---------------------- --�.!_j-----.._........._.... ..................
x
--------------------------------- •--------------..1�P.-.l''.-
W------------•---------------------------------•-----------------------------------------------------------------•-----------------•---------•---••----••--•-•-------•••---••••---.........---------•-•.
UNature of Repairs or Alterations — Answer when applicable ...............................................................................................
-•----------------•---------------------------------------•--•-•••--•---•-•-----•---.........-'••••-------•-•-•-•---•------------------•-•••--•-----•-- ...............................................
Agreement:
The undersigned agrees to install the aforedescribed Individual Sewage Disposal System in accordance with
the provisions of TITs,I�. 5 of the State Sanitary Code — The undersigned further agrees not to place the system in
operation until a Certificate of Compliance has b en issued ty th board of health. (�
Signed_� S ......................... -=fir-- aq_` E
Date
Application Approved By..- C r r,r------------------------------ -_ __�_ ,Y........
Date
Application Disapproved for the following reasons: •-----------•----------------........
.----------------------•------•-•....-----•--------------------------------------•---...----•----------•---••--•-•-•••-•-•-----•-------------•••-----••------------•----••-•......
Date
Permit No.....s Zl' � �Pl.......................... Issued.---- C ......................
Date
THE COMMONWEALTH OF MASSACHUSETTS
BOARD OF HEALTH
............... '/.vii..::- '✓..........OF �'.....r.:..:s:z..r.:..........'Z.......................................
Trrtifkatle of Toutpliana
THIS IS TO CERTIFY, That the Individual Sewage Disposal System constructed (-- 7'or Repaired ( )
by.....'/ .. _.......'.•'
Installer
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...E_;r__:__? 1 ............... dated__-f:..:.,f_. .....................
THE ISSUANCE OF THIS CERTIFICATE SHALL NOT EE C RUE® AS A GUARANTEE T THE
SYSTEM WILLr UNCTION SATISFACTORY.
DATE......... . -- -- ........-"......-----•.... Inspector--- ---- ------ ----- - ----- -- ---- •-•-• . . --•• ... ......