HomeMy WebLinkAboutApp-Permit-ComplianceNo�.....�:?�% Fu$..............................
THE COMMONWEALTH OF MASSACHUSETTS
BOARD , HEALTH
�- J�
..........................................OF.... .................�r •••�•----- ---- ............ -. ---_._.__..._...------.
Appliration for Disposal Works Tonstrurtion Prrutit
Application is hereby made for a Permit to Construct ( ) or Repairan Individual Sewage Disposal
System at*
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..............._. .-----•----••-•---...._....... •--- .........._........_...... - -•--..................----•-.......------------------------•-••........... • .._..
cation A dr s or Lot No.
.d._..:..�.'r�--iJ-•"s./ '�............. .... .. �:... !:�. _ ...._...... ......--•"'e•-�--- /Clf::' --•---...---•-•----------•--•----•-----........_...---
Owner - = Address
--------------�/ ...... ? ................. ...... 1.._.A....-- �......----------------------......--------------....------------...
Installer Address
Type of Building
Dwelling —No. of Bedrool
Other —Type of Building
Other fixtures .....
Design Flow ----------------------------------- - ------gallons
Septic Tank — Liquid capacity ... _.-___
Disposal Trench — No ................... Wid .....
Seepage Pit No ..................... is eter............
Other Distribution box ( ) Dos n
Percolation Test Results P rformed by,..
Test Pit No. 1 ................ inutes per inch
Test Pit No. 2................minutes per inch
Description of Soil -•---------------------------------
Size Lot ............................ Sq. feet
.................Expansion Attic ( ) Garbage Grinder ( )
No. of persons ............................ Showers ( ) — Cafeteria ( )
Ser person per day. Total daily flow............................................gallons.
Length ................ Width ................ Diameter ................ Depth....------......
............. Total Length .....................Total leaching area -------------------- sq. ft.
..... Depth below inlet .................... Total leaching area .................. sq. ft.
tank ( )
---------------------------------------------------------••--••-•.... Date ........... >............................
Depth of Test Pit .................... Depth to ground water ........................
Depth of Test Pit .................... Depth to ground water. .......................
...................................................... -----•. -•-...•-••••-•--•-----•--------•---.............•--....--
-------•--•-...----•••-----------•-----•-•--------•----------•-----.....--••••--•---•-----••••-•-•-•-------------------
------------------------------------------------------------------------------------•-------..............---------•-•.
-----•--
--------- --- ---------
Nature of Repairs or Alterations —Answer when applicable �_______________ _______�? _ ��//� ........ -------
Nature ..-...-..-------�-
Agreement :
The undersigned agrees to install the aforedescribed Individual Sewage Disposal System in accordance with
the provisions of TITIE 5 of the State Sanitary Code — The undersigned further agrees not to place the system in
operation until a Certificate of Compliance has been issued by the board of health.
Signed =.................................................' .................../_.aie
----
f�' d
Application Approved By... ----------....... ...... ...__.... ...................................................... ----r - ------------
D
Application Disapproved for the
fol
olio ng reaso s: ............. •-------•--••---•-••-•---••-----•----••--•-----•---•--------•-•--••-•-•-•....
Permit No.
•-----•--•..................................................... ........................
Date
Issued.......................................................
Date
THE COMMONWEALTH OF MASSACHUSETTS
BOARD OF HEALTH
.......................................... OF..�/."......................................................................
Tatifirair of Tontpliatta
THIS IS TTRTIY, Pr tl$dividual Sewage Disposal System constructed ( ) or Repaired (/
by-----•--•---------------------•--------•------•----•-------------•�••----�----------------•-----------------------------------•-----------------------------------•----------•--•----•----•---•---
Ins ��/ /J4A t��
.._�............ ---- --------•--•------------------------•---------------------------•------
at�... _. ...
has been installed in accordance with the provisions of T - Cod ��................... dated•_. �/ 1/--- I............................
THE ISSUANCE OF THIS CERTIFICATE SHALL NOT BE CO TRUE® AS A f GUAR/ANTE
�THAT
THE
SYSTEM WILL F C O SATISFACTORY. Inspec...............................