HomeMy WebLinkAboutApp-Permit-ComplianceTHE COMMONWEALTH OF MASSACHUSETTS
BOARD OF HEALTH
OF..................................... I ---------- ...... -•.... -.............................
Appliratilan for Diapaii al Workfi C omunrtiun Vamit
Application is hereby made for a Permit to Construct ()C) or Repair ( ) an Individual Sewage Disposal
system at- ....... --•---•------------- t -...........
r�� �� . �. DoT- YY� ►� ��q
jL cation - , dress/ -- Lot No.
.2�,:1� ..{.3.----- -- •-•�•- - - ---•-------- •-�-•-- .:.----- Add - --'---•........ ...:................
Owner 3
I %�fL ress
a
.................. ,4 ------. ...._. � ��..----•.......................... .................................................. "` ---------------------
Installer Address
-----------------------------------------------------------------------------...................... -----•---•••••••----•••------- ------------------•----------------------------------------------
Agreement :
The undersigned agrees to install the aforedescribed Individual Sewage Disposal System in accordance with
the provisions of 'TT
� � .-E Sof the State Sanitar Code The and signed further agrees not to place the system m
operation until a Certificate of Compliance has en issued by the and of healt
Si ned•• ••. - - ................... -- ---•- .....
`Da I
Date
Application Approved BY .......
�l
Date -
Application Disapproved for the following reasons:-•------••---------------------•-------------------•---•------•----------------------------•••-•-•-•-••---------
•----•-------------------'----------------________ ____----------•------------ ••••••---•------• ................
PermitNo --------------------------------------------------------- IssuedL -------------------------------------------------
Date
THE COMMONWEALTH OF MASSACHUSETTS
BOARD OF HEALTH
.......................................... OF .....................................................................................
Trrfffira tr of TompliFanrr
THIS TD—C,.E;RTIFY, That the Individual Sewage Disposal System constructed (N) or Repaired ( )
Y--
rz
+° i, Installer
.Y+� w-
at-�---�"-�- `"""�-- -- ----- �� �.................
---
has been installed in accordance with the prow' ns of TITLE j of The ate tart' Code as escribe in the
application for Disposal Works Construction Permit No. ___ yr+ �" _ dated___._""' � _ ,__: ____
THE ISSUANCE OF THIS CERTIFICATE SMALL P OT BE CONSTRUED AS A GU ANT THAT THE
SYSTEM WILL FUNCTION SATISFACTORY.
DATE................................................................................ Inspector ....................................................................................
Type of Building
Size Lot__ I z ........ _?-:_rOSq. feet
Dwelling —No. of Bedrooms ._______..__.".......................... Expansion Attic (
) Garbage Grinder ( )
Other — Type of Building ____________________________ No. of persons____________________________ Showers ( ) — Cafeteria ( )
P+
W
Other fixtures _-----•---•-•••-----------•-•-•--•-•••• -
Design Flow_,44-62--•-----_______•_�---=-^,gallons per person per day. Total daily
flow ....... .-2-................... gallons.
WSeptic
Tank — Liquid capacityl __ allons Length ................ Width ................
Diameter ................ Depth ................
x
Disposal Trench — No_ ____________________ Width .................... Total Length ....................
Total leaching area .................... sq. ft.
Seepage Pit No --_---------------- Diameter .................... Depth below inlet ....................
Total leaching area .................. sq. ft.
Z
Other Distribution box ( ) Dosing tank ( )
'-�
Percolation Test Results Performed by .......................................................................... Date ........................................
aTest
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 ________________-______-
------------------------------------------------------------------------ •-•-•---•------•------------
--------••--------------------•-----------------------••-
0
Description of Soil--------------------------------------------••---------._......-----------•----------------------------------------•---•---------------------------------------------•-
V•-•---•---•--•-----•-•-------------------------•-------------------•-•-•---------•---------____--•----------•------------------------------•----•-----------------------•--------•------•---------------
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 'TT
� � .-E Sof the State Sanitar Code The and signed further agrees not to place the system m
operation until a Certificate of Compliance has en issued by the and of healt
Si ned•• ••. - - ................... -- ---•- .....
`Da I
Date
Application Approved BY .......
�l
Date -
Application Disapproved for the following reasons:-•------••---------------------•-------------------•---•------•----------------------------•••-•-•-•-••---------
•----•-------------------'----------------________ ____----------•------------ ••••••---•------• ................
PermitNo --------------------------------------------------------- IssuedL -------------------------------------------------
Date
THE COMMONWEALTH OF MASSACHUSETTS
BOARD OF HEALTH
.......................................... OF .....................................................................................
Trrfffira tr of TompliFanrr
THIS TD—C,.E;RTIFY, That the Individual Sewage Disposal System constructed (N) or Repaired ( )
Y--
rz
+° i, Installer
.Y+� w-
at-�---�"-�- `"""�-- -- ----- �� �.................
---
has been installed in accordance with the prow' ns of TITLE j of The ate tart' Code as escribe in the
application for Disposal Works Construction Permit No. ___ yr+ �" _ dated___._""' � _ ,__: ____
THE ISSUANCE OF THIS CERTIFICATE SMALL P OT BE CONSTRUED AS A GU ANT THAT THE
SYSTEM WILL FUNCTION SATISFACTORY.
DATE................................................................................ Inspector ....................................................................................