HomeMy WebLinkAboutApp-Permit-ComplianceNo. .--• ®•'-°_ Fzs ..............................
THE COMMONWEALTH OF MASSACHUSETTS
—_---BOARD F HEALTH
.........OF...........--=---------------------------------------------------------
Appliration for R-spniia1 Works Tonstxnrtion Vanat
Application is hereby made for a Permit to Construct ( ) or Repair an Individual Sewage Disposal
System at:
�o f L l
/
- j _ .. .......................-----------......------.........----- -
.........� - - . -
ocatiiAd ess or Lot No.
...---•------td=---.e..._ .. .. -F--e . .......' ......................^_........................................................................................................
.. ............................... Address
Own
-------------------•---•-- •--- ---•------------ .....� . e.....---------------
Installer Address
Type of Building Size Lot. ........................... Sq. feet
Dwelling —No. of Bedrooms............................................Expansion Attic ( ) Garbage Grinder ( )
Other — Type of Building ............................ No. of persons ------_.. _--......._-.-_- Showers ( ) — Cafeteria ( )
Otherfixtures -------------_-_--_.............................................................. .............................................................
Design Flow --------------------------------------------gallons per person per day. Total daily flow -------------------------------------------- gallons.
Septic Tank —Liquid capacity ............ gallons Length ................ Width ................ Diameter ................ Depth ................
Disposal Trench — No- -------------------- Width .................... Total Length .................... Total leaching area .................... sq. ft.
Seepage Pit No -_--_------------- Diameter .................... Depth below inlet .................... Total leaching area .................. sq. ft.
Other Distribution box ( ) Dosing tank ( )
Percolation Test Results Performed by .......................................................................... Date ........................................
Test Pit No. 1................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 ------------------------------------------------------------------------------------------------------------------------------------------------------------------------
------------------•------------•--••----------•--•----...................................................
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 TITTIL 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.
Si d
Date
Application Approved By .............°'r-� - 2.�...y, . 7✓� ; �t� 7r��'
llate
Application Disapproved for the following reasons----------------------------------------------------------------------------------------------------------------
by
Date
PermitNo --------------------------------------------------------- Issued --------------------------------------------------------
Date
THE COMMONWEALTH OF MASSACHUSETTS
BOARD OF HEALTH
— /;, t �/,
...............C..4 4r13%J........OF......../.:..............:.......................................................
Tatifirtttr of f911ntplutnrle
THIS IS TO CERTIFY, That the Individual Sewage Disposal System constructed ( ) or Repaired (�
A' '' - t''"----------------------------------------------------------------------•----------------------------------..-.-------------------------•-----`-
Installer
at.....................• -r` . acs.. a'= ==------. hx== = -------------------------------------------•-----------•-------------•------------•--------------------
has been installed in ccordance with the provisi of TIT I 5 of`The State Sanitary C -cid a_s escri i the
__. '
application for Disposal Works Construction Per it No..__ _�a._•..r - :,._._....: dated ----
-- ,.%
THE ISSUANCE OF THIS CERTIFICATE SHALL NOT BE CONSTRUE® AS A GUARANTEE THAT THE
SYSTEM WILL FUNCTION SATISFACTORY.
DATE................................................................................ Inspector -------------------------------------------