HomeMy WebLinkAboutApp-Permit-ComplianceNo.. _�,�'. Fw%- 4 ................
THE COMMONWEALTH OF MASSACHUSETTS
BOAR® OF HEALTH
. ........................................ OF.........................---...........--------.........---.....................---•--•---
Appliration for Utgpvii al Works Tonotxnrtion pamit
Application is hereby made for a Permit to Construct ( ) or Repair (-.>Q an Individual Sewage Disposal
System at:
... ....... 's C.l....... /�/'•-K -- ,/ • — l -
ion - Addr s oor Lot No ........... ... . ..............
c f No
• o
wner Address
a ..................................... -•----•-------------•-----......--••----...-
Installer Address
d Type of Building Size Lot ............................ Sq. feet
aDwelling —No. of Bedrooms -------------------------------------------- Expansion Attic ( ) Garbage Grinder ( )
p, Other —Type of Building -•-____-------•__--.__---•- No. of persons ............................ Showers ( ) — Cafeteria ( )
P4 Other fixtures -----•-- --•-•-•----•-----•----- -
W Design Flow............................................gallons per person per day. Total daily flow ............................................ gallons.
WSeptic Tank — Liquid capacity ............ gallons 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 ( )
PercolationTest 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 ........................................................................................................ ...............................................................
•••-•------------•-----•--•----•-----•---•--•-•-----•---•-•-•••---•-------------•-•----•-•••---•------•-------•------------••-•--•-----------------------•---•--••----•------•---------•--•--------•--
W--------------------- ---------------------------------- --................................................................................................................ ---.........................
VNature 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 :I`: LE y g g P Y
5 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.
Sined.-•---------------------------•--•---•-•-•-•-......--------------........._....-•--
Date
Application Approved BY------------- ✓1 -- ` 77.��--�Lfa�ns ?�... Date
health Officer
Application Disapproved for the following reasons----------------------------------------------------------------------------------------------------------------
..................................... .............. -..................................................................................................... ..............................................
Date
PermitNo ......................................................... Issued --------------------------------------------------------
Date
THE COMMONWEALTH OF MASSACHUSETTS
BOARD OF HEALTH
.......................................... OF .....................................................................................
Tn#ifiratr of Toutph arta
THIS IS T,( ERT Y, That the Individual Sewage Disposal System constructed ( ) or Repaired O
.... yr C` ' ---"-
r•; �,' �' "' Installer ,r
"---------------- --�5e-�"-=='=---------•------------
has been installed in accordance with the provisions of TITLE j of The State San' y CoZdes desc *bed in the
application for Disposal Works Construction Permit __THE ISSUANCE OF THIS CERTIFICATE SHALINT BE CON TRUE® AS A GUN E T6�AT THE
SYSTEM WILL FUNCTION SATISFACTORY.
DATE-------------------------------------------------------------------------------- Inspector ....................................................................................