HomeMy WebLinkAboutApp-Permit-ComplianceNo.. . _.:.� FRs
THE COMMONWEALTH OF MASSACHUSETTS
BOARD OF HEALTH
.............. O F..........................---•--•.....-----------------------------..._...._....._...-----
Appliratiou for Di-sposal Works Toustrurtioo famit
Application is hereby made for a Permit to Construct ( or Repair ( ) an Individual Sewage Disposal
System at:
v ----•
--.......... o...._ - ��1 .............. ... ....
- Location - Address- . or Lot No.
,�.Z-" -------------- ---------------•-•----------------......------............._..
Owner Address
Installer Address
dType of Building Size Lot ............................ Sq. feet
Dwelling —No. of Bedrooms ............................................ Expansion Attic ( ) Garbage Grinder ( )
'_la Other — TyPe of Building No. of persons............................ Showers Cafeteria
( )
a Other fixtures
....
W ..........:................gallons pe day. Total daily flow ............................................ gallons.
Design Flow -_..11
W Septic Tank — I.iquid' capacitylo
�o.gallons Length -__.-R ...... Width ..... �_r._
,.... Diameter---------------- Depth_.. _-......
x Disposal Trench — No ........... ......... Width .................... Total Length ..................... Total leaching area -----
ft.
Seepage Pit No..._...�..___.___. D' meter..® e._�.a5__.... Depth below inlet-.�.e_�..... Total leaching area57_4, 0 r_ `�,1__._�•sq. ft.
Z Other Distribution box ( Dosing tank ( ) j
'-' Percolation Test Results Performed by..Z9ew-J ...... !sem _____ ,r _ _.._._. Date_..`. ---
Test Pit No. 1 ................ minutes per inch Depth of Test Pit .................... Depth to groun water ........................
(i Test Pit No. 2................minutes per inch Depth of Test Pit ............... _.... Depth to ground water ........................
a--•------------••-••--•-•--•----------------------------------------------------•----------.._...---.........................................................
O Description of Soil ......... ....... �9`
x
W........... -----------------------------------------•----•-•--•-•---•---•----•--•-•----•----•-•-------......--------------------•------------------•---••---•-------- .................................
U Nature of Repairs or Alterations — Answer when applicable .___________________________•---................... .............................................
---•-•---•--•-----------------•------•.....---••-----••....--------------------------------------...•-----....----•-------•-----•------•-••-------------••---•-•-..._..••--------••---•----------------
Agreement :
The undersigned agrees to install the afored9e6N Individual Sewage Disposal System in accordance with
the provisions of TITLE 5 of the State Sanitary ode — he unders' further agrees not to place the system in
operation until a Certificate of Compliance5ighasbbe'Issued y the b rd of iealt .
�' ` ---- --- - ---- ----_----------•--------------
/ Date
Application Approved By .................. ..�9..c -._ ...-----•---------•----- ---- [e%
Date
Application Disapproved for the following reasons: ____
Permit N
----•-----•--................
Date
Issued.......................................................
Date
THE COMMONWEALTH OF MASSACHUSETTS
BOARD OF HEALTH
.......................................... OF .....................................................................................
Tatifiratr of f-ompliaurr
THIS IS TO CERTIFY, That the Individual Sewage Disposal System constructed ( ) or Repaired ( )
by ---------------------------------------------------
Installer
at------------------------------------------------------------------------------------------------------ -----------------------------------------------------------------------------------------------
has been installed in accordance with the provisions of TITLE: j of The State Sanitary Cid a=TEETHAT
the
application for Disposal Works Construction Permit No .... dated__..C_c_: ___�..._......
THE ISSUANCE OF THIS CERTIFICATE SHALL NOT BE CONSTRUED ASA ARA THE
SYSTEM WILL FUNCTION SATISFACTORY.
DATE................................................................................ Inspector