HomeMy WebLinkAboutApp-Permit-ComplianceNo.. ............. _..... I ol- c FEs.... ......_
THE COMMONWEALTH OF MASSACHUSETTS
BOARD OF HEALTH
..................... n..............OF....
Appliration for Disposal Varks Tonstrudion fermi#
Application is hereby made for a Permit to Construct (X) or Repair ( ) an Individual Sewage Disposal
I
__-System at: .�
3q
Location
Location -Address,^ 4�r. Lot No.
................ -.... -.--...................................................................... ------------•. ^ r -f " .....1 ^ - _.. ...................... _..............
Owner Address
W
a
P4
a
Wd
W
x
Z
404w
:a
x
U
W
x
U
Installer Address
Type of Building Size Lot ........ 11 4— Z -..Sq. feet
Dwelling —No. of Bedrooms ........... .............................Expansion Attic ( ) Garbage Grinder ( )
Other — Type of Building ............................ No. of persons ............................ Showers ( ) — Cafeteria ( )
Otherfixtures ............................................... - ...... -------------- ..... ----------- .---------------------------------- ----------
Design Flow ............ �J ........................gallons per person day. Total dal tow.._................................... �}}to
Septic Tank — Liquid' ca.pacity.l�'�.gallons t L h..2_.. Width:... ?.. Diameter ................ Depth..`�C_..!
Disposal Trench — No......I............. Width- 1 t Total Length.Z%...._ . --Total leaching area. -,M sq4. t- G J(D
Seepage Pit No ..................... Diameter .................... Depth below inlet .................... Total leaching area .................. sq. ft.
Other Distribution box (X Dosin to ( ) .
Percolation Test Result ,� Performed by.__�r...`�!.h._�._ _ _� Date_.S 3c' 8�
..............•--- - I Ij ..
Test Pit No. I...............minutes per inch Depth of Test Pit-- �.' ........ Depth to ground water .... .. _4......._..
Test Pit No. 2................minutes per inch Depth of Test Pit .................... Depth to ground water ........................
..............
Description of Soil.... .. o ` .
-----•----•-------------•----------•----------------•-------..._...---...-------------•---....-----•---------
Nature of Repairs or Alterations — Answer when applicable....
0
--•-----•--•-------•------...--•.........................•-•--------•----•-•----.......----•----...----•-•-•---........---...........-•----•----•--------••----•-••----......--------...................
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 n issued byoar of h Ith.
Signed... •---........... -••-------•�P�..'..�'�
Application Approved By......... ._ ...... ......... ...................
....•---.......-- •--••••..1� ` .. ..........
Date
Application Disapproved for the f ollowir
-----------------•-----..............---......../. •---........----• ----
Permit No....-� V --------S-. -- .
reasons: -•--------------------------------
aq
Date
THE COMMONWEALTH OF MASSACHUSETTS
BOARD OF HEALTH
........... ..................OF.... ................. ....................................................
(Irrtif iratr of woutpfittnrle
TfIIS IS TO CERTIFY, That the Individual Sewage Disposal System constructed Com) or Repaired ( )
by ....Installer
at
---- ----
has been installed in accordance with the provisions of TITLE 5 of The State Sanitary Code ases Abed in the
application for Disposal Works Construction Permit No._ : --_5_-x-2 . ............... dated... �n�.?l...� _.._.....................
THE ISSUANCE OF THIS CERTIFICATE SHALL NOT BE CONSTRUED AS A GUARANTEE THAT THE
SYSTEM WILL FUNCTION SATISFACTORY.
DATEl ,i ................................................... Inspector ....?...��.� �y , f