HomeMy WebLinkAboutApp-Permit-ComplianceN037-26
THE COMMONWEALTH OF MASSACHUSETTS
BOARD OF HEALTH
.W..... ''......... OF ....... . �f..N!Iii."1........................................
Applutt#ilatt fnx Disposal Works Toush-urtion f rrmi#
Application is herebyi made for a Permit to Construct ( ) or Repair ( L) -an Individual Sewage Disposal
System at: Z -0-r
.......... .... Loclon. Address� -•------• ............. ............. . or Lot -No. ........... •................
------
......................................... .............•-.. ...........4�`�...
CJt:: Address..... ..........................
Installer Address
Type of Building Size Lot ............................ Sq. feet
Dwelling —No. of Bedrooms---S...................................Expansion Attic ( ) Garbage Grinder ( )
Other — Type of Building ............................ No. of persons ............................ Showers ( ) — Cafeteria ( )
Otherfixtures ---------------•--------------------------------------.---------------•-----------.------------------..-_-_--•----------------------------------------
Design Flow ......... �.-------------------- gallons per person day. Total daily flow ......... ...................gallons.
Septic Tank — Liquid'ca.pacity�,�7gallons Length ..... ......... Width .......... Diameter................ Depth ................
Disposal Trench — No. ....I .............. Width .... Z..h ----- Total Length .... as_ ..... . Total leaching area ................... sq. ft.
Seepage Pit No ..................... Diameter .................... Depth below inlet -_-a_!......... 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 i r Alterations -Answer when ........ Lmrv....
'
_....di24, �.......--------------------------------------------
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 #e
Application Approved By...........
I
Application Disapproved for the
PermitNol.Fl R ............................... .._.._
THE COMMONWEALTH OF MASSACHUSETTS
BOARD OF HEALTH
.......... /
..........................
7 Date
........... .. :'�, IA.� '!%.:`- OF ......... ..}V17. r.S -......................................
Trr#iftrate 'of Tompffitnrr
THIS IS TO _.GFIT.IFY, That -the Individual Sewage Disposal System constructed ( ) or Repaired
by= -.........3 j .��......................•--........------.................----.......----......._..........
I staller
has been installed in accordance with the provisions of TSI � of The State Sanitary Code-0..scr,}h ln� the
application for Disposal Works Construction Permit No._:.4............................... dated_..�.. _ ...--...../.... ..........
THE ISSUANCE OF THIS CERTIFICATE SHALL NOT BE CONSTRUED AS GUS eNTEE THAT THE
SYSTEM ILL FUNCTION SATISFACTORY. —c
........ t
DATE.. .:/-/�f Inspector-. '� z i
2V..�:................
..j - ......... ... d