HomeMy WebLinkAboutApp-Permit-Complianceo.. ........ ..
THE COMMONWEALTH OF MASSACHUSETTS
BOARD OF HEALTH
...................... .................... OF ...........................................
...........
Appliration for Disposal Forks Tonstrnrtinn ramit
Application is hereby made for a Permit to Construct ( ) or Repair an Indi idual Sewage Disposal
System at: � r'/
.-.- Locati Addre or• Lot No.
' •' _.. l`l .. ...........................
••............. ........._...--
Owner Address
........ .....--•-------------------------------------------•--------------_..-----•------•------••--•--•-••----•-------...........................•...
Install 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-----------------------------------------------------------------------------------------------------------------------------------------------------------------------
-------------•--------------------------------------•-----•-----------------......-----------•--•-•------------------------
----------->- C•�-----•----------
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 TITIZj 5 of the State Sanitary Code — The undersigned further agrees not to place the system in
operation until a Certificate of Compliance has been,*yed by/the board of health.
Application Approved By
Application Disapproved for the following jf�dsons: __-
9- ------------
----------------
..................... ...... ---.at�---
---------•-----------------•--•--------------•----------•-------.......------.
.-----------------------------------------------------------------------------------------•--•-----------•---------------••--------....................................................
Date
PermitNo. -•--•-••---•--------------•-•-•--- Issued..--------........ -----------
ate
THE COMMONWEALTH OF MASSACHUSETTS
_ BOARD OF HEALTH
........... c%fCf /I ....... OF ......../........................................................
(Entifiratr of Tnntpliattrr
THIS,.It TO C FY, That the Individual Sewage Disposal Slstem constructed ( ) or Repaired
. - �-
by-•-•...--•-• ••............. .• - ---- -----------.........
l 2
stal .
at----------------------------------------------------------------- - - ------------ y -
has been installed in accordance with the provisions of TI > f The, tate Sanitary ode s described in the
-._ s_
application for Disposal Works Construction Permit No. — -:-___ dated__`��A�R
� ... .....................
THE ISSUANCE OF THIS CERTIFICATE SHALL NOT CON TRUE® AS A G NTEE T THE
SYSTEM WILL
/FUNCTION pSATISFACTORY.
DATE.......... �f,�• ...............•------------........ InsP� .....