HomeMy WebLinkAboutApp-Permit-ComplianceNo., ../.�C!..Z Fus..../..C.
THE COMMONWEALTH OF MASSACHUSETTS
BOARD OF HEALTH
............. ........................O F.........................--------.....-----------------------._.................._........
Applira tion for UhnVatial Works C onotrurtiun Vamit
Application is hereby made for a Permit to Construct ( ) or Repair (�) an Individual Sewage Disposal
2 System at:
...................... ...... .......................................... � i o
if �:rc,��.�__......-• - ------------�-•--------� ---
a
. -Address or Lot
No.
G- ........
.. ................ O Address
------... ......•......
Installer Address
Type of Building Size Lot ............................ Sq. feet
Dwelling —No. of Bedrooms ............................................Expansion Attic ( ) Garbage Grinder ( )
4 Other — Type of Building --------------_----._.---- No. of persons ............................ Showers ( ) — Cafeteria ( )
4 Other fixtures ----------------------------------------------
Design Flow............................................gallons per person per day. Total daily flow ............................................ gallons.
4 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 ........................
4 Test Pit No. 2................m>nutes per inch Depth of Test Pit .................... Depth to ground water .-____-------.__--______
Descriptionof Soil-------------------------------------------------------------------------------------._
---------------------•------•--•-•-........................................................... --•-•--------•--------•-----•--•-------------•------•---•-- ---...---------------------------•-----
------------------------------------------------------------------------------------------------------------------------ - --
------------------- - -- -
Nature of Repairs or Alterations — Answer when applicable.""'_____. f
Agreement:
The undersigned agrees to install the aforedescribed Individual Sewage Disposal System in accordance with
the provisions of T T i,• y g g p y
of the State Sanitary Code —The undersigned further agrees not to lace the system in
operation until a Certificate of Compliance has been issued by the board of health.
igned......... --------------------------------------------------------------------------- ............ Da.te..............
Date
Application Approved BY -------- �" • - -- -- -g-•---- - -• - - u--- ---------------------------- Date
'WSWApplication Disapproved for th.VWb n ��¢�s��t.�.•..................................................................................... _--_------------------
................................... -------------------------------------
Date
PermitNo --------------------------------------------------------- Issued .......................................................
Date
THE COMMONWEALTH OF MASSACHUSETTS
BOARD OF HEALTH
.......................................... OF .....................................................................................
%luntifiratr aaf fl outpliaurr
THIS IS,TO RTIFY, That the Individual Sewage Disposal System constructed ( ) or Repaired (,
bY................ 4- `--- -------------------------------•--- - -------------------------------•----•-----•-----------------------•-----...---...---•-•--•--•---•-----
� J staller
1/ ,,• L.
at.. � /-------------•- .12 711--11 ._ /<------- - = ...---- %-----................................................................
has been installed in accordance with the provisions of TITLE j of State Sanitary Code as described in the
application for Disposal Works Construction Permit No.___-_/-./_'__'"_-- �"___'"�' dated .......
THE ISSUANCE OF THIS CERTIFICATE SMALL NOT BE CO "TRUE® AS A GUARANTEE T AT THE
SYSTEM WILL F CTI N SATISFACTORY.
r Y 1=5;
"{t
DATE-----•---`� '��� Inspector..