HomeMy WebLinkAboutApp-Permit-Compliance(1
No.._'..,�.4 Fizz .............................
THE COMMONWEALTH OF MASSACHUSETTS
OF HEALTH
1.... UZr...0 F.....................................................................................
Appliration for Disposal Worksontrurtion anti#
Application is hereby made for a Permit to Construct ( or Repair ( ) an Individual Sewage Disposal
stem at
.................
Location - Address or Lot o.
--_E.......,� ...7om-
Owner Address
Installer 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.................................--......-•-•----------------------- ------•--------•----------------•--------............__....•---
`� 11cv gallons.
Design Flow ....... 1'/ -----------------------gallons per $ePse�r-�e>; ay. Total daily flow------------ --------...._.
Septic Tank — Liquid' capacat Z allons Length_..__..... Width___.,_...____ Diameter ................ Depth.. ._......
Disposal Trench — No ..................... Width .................... Total Length .................... Total leaching area __. ;q. ft.
Seepage Pit No -------- ,� ....... Diameterl� �_ ____. Depth below inletAi tom_____.... Total leaching area .�..---sq. ft.
Other Distribution box Dosing tank
y o�v�J Date.._,�t� ..�
Percolation Test Results Performed b______________________ ---------------- -
Test Pit No. 1................minutes per inch Depth of Test Pit .................... Depth to ground wa .........
Test Pit No. 2................minutes per inch Depth of Test Pit ............ _....... Depth to ground water. .......................
•--•-------------------------------••-------...----------------••-----------•-•-••--•------ - -------•------
Description of Soil ...... '=f? �?-� ...
--------------------------.................................
•---------------------------------------------------------- -----------------------------•--------------------------------•---
Nature of Repairs or Alterations — Answer when applicable ......................
Agreement:
The undersigned agrees to install the afored crL—he
idual Sewage Disposal System in accordance with
the provisions of TITI-E, 5 of the State Sanitary cledersiUoofl4ealth.
grees n to place the system in
operation until a Certificate of Compliance has bee sbo d Signed,- . -------- ----------•................................
Date
Application Approved By------••-------••-•--- . .. ...- r L%
Date
Application Disapproved for the following reasons: .................................................................
-------------------------------------------------------------------------------------------.----------------------------------------...------------------. ----------------------
Date
PermitNo --------------------------------------------------------- Issued ------------------------------------------------------
Date
THE COMMONWEALTH OF MASSACHUSETTS
BOARD OF HEALTH
.......................................... OF ..................................................................................... F.....................................................................................
Trdifirat a of Tontplianrr
THIS, IS W CRRTIFY, That the Individual Sewage Disposal System constructed (or Repaired ( )
by.... ------------------------------------------- ------------•-----------------•---•--•--------•---------------------------------
.. stal-�----- ---
at. .... ... /f ..----1 - �'/ -----------------------•------.....-------•----------------•---------------
h n installed in accordance with the rovisions of TIT �' The State Sanitary Code as escri ed in the
as been
application for Disposal Works Construction Permit No.-/�----- Q----•---------- dated-__.______ _�_�E
THE ISSUANCE OF THIS CERTIFICATE SHALL NOT BE CONSTRUE® AS A GU ANT E THAT THE
SYSTEMA WILL FUNCTION SATISFACTORY.
DATE-------------------------------------------------------------------------------- Inspector----------------------------------------------------