HomeMy WebLinkAboutApp-Permit-ComplianceY
No..._l .:r .... . ....... 1
THE COMMONWEALTH OF MASSACHUSETTS
BOARD OF HEALTH
I.e�w of................Y)"Ll." .v`I�'�
Appliration for Elispniitt1 Works Tonstrnr#iun 1hrmit
Application is hereby made for a Permit to Construct ()L.) or Repair ( ) an Individual Sewage Disposal
System at:
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--°......................... ........... - _.------- - ocatdion - Address
0 or Lon No.r _ n .. A
--------.IVA
Address
Installer Address
Type of Building Size Lot -_-1S oo a_____ - Sq. feet
Dwelling —No. of Bedrooms............ --------------- ----------Expansion Attic ( ) Garbage Grinder ( )
Other — Type of Building _-__-____-------------_-- No. of persons ............................ Showers ( ) — Cafeteria ( )
Other fixtures ...................................
Design Flow ---------.-I-w-�...........................gallons per parson pier day. Total daily flow ........... 44P ...................... gallons.
Septic Tank — Liquid capacity!j2dP_.gallons Length_. .7�_ ---- Width.4�7!IQ _. Diameter ................ Depths.-¢`
Disposal Trench — No ..................... Width .................... Total Length .................... Total leaching area --_----.-•-_•-----.sq. ft.
Seepage Pit No �............. Diameter ........ 1.t"�___ X __- Depth below inlet.....b_% --------- Total leaching area. Z -7 ----•-sq. ft. }
Other Distribution box ( /4 Dosing tank ( )
Percolation Test Results Performed by.--__--_ 12_ -- :. O -K = �._. .......................... Date..._ I— _0 ..................
Test Pit No. ...__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 ........................
Descriptionof Soil ............ b -L30 .... 7--- ............................. o. -----T #r.......................................................................
..
-1M5�..x=....------------•--....--•-------.....------------.....------.
-•-•------------ ------------•-----•------------••---------•---•-----•---•-----------•--•----•----••-••-•-•---•------•-----•-•-----•----------••--•-•------•...----•-•-----------.....-•----------------
Nature 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 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 >board ni health. `
---= 5 --
Application Approved By.- --•-•----••---- . ---•• .... = -Zi - t
Dat
Application Disapproved for the following reasons---------------•-----------------------------------------------•-------------...------------------------------•--
......................................... .....------------...--------------•---•-•----•---•--------•-----------•------ ------ .................
Sto
PermitNo ----------- ...... ----------•--------................. _ Issued. --------- --------------------•-- ....................
Date
THE COMMOWVEALTH OF MASSACHUSETTS
BOARD OF HEALTH
.......................................... OF .....................................................................................
Trrtifiratr of Tl mptiatta
THIS IS TO CERTIFY, That the Individual Sewage Disposal System constructed ( ) or Repaired ( )
Installer
at......................................................................................................................................................................................................
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---------------------------------------- dated ................................................
THE ISSUANCE OF THIS CERTIFICATE SHALL NOT BE CONSTRUED AS A GUARANTEE THAT THE
SYSTEM WILL FUNCTION SATISFACTORY.
DATE................................................................................ Inspector