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Home My WebLink AboutApp-Permit-ComplianceNo. S�.Cw& Fics..h. E .... ...... . THE COMMONWEALTH OF MASSACHUSETTS BOARD OF HEALTH ................... OF ...(A:.ULX:NN.!......_....----------._.... ......----......._..... Appliration for Disposal Works Toustrurtinn jkrutit Application is hereby made for a Permit to Construct System at .. -Locat' n -Address ._.. / j Installer ) or Repair ( ) an Individual Sewage Disposal .......--•'•'--Lb+T l'u\�► q ?.......•...!2 �a E..!_► -3 ........................ 6-.....Vt 1 1&C !`7 = — Lot No .................• ...._.............- --� Address Type of Buildingy� Size Lot ............................ Sq. feet Dwelling—No. of Bedrooms.........!?..............................Expansion Attic ( } Garbage Grinder ( ) Other — Type of Building ............................ No. of persons ............................ Showers ( ) — Cafeteria ( ) Otherfixtures ......................•-•-•-........._....--•---------.•----........------_.........-------•..........._.-----------------•--•---•--------•----------- Design Flow...... ............................gallons per person per day. Total daily flow-_ ............................. gallons. 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 ........................ Test Pit No. 2................minutes per inch Depth of Test Pit .................... Depth to ground water ........................ ---------------------------------------------------------------------------••-•-••-•-••------••-••_.-•----•••-----......_•-•---_---•---•--_-•-_.....--.---... Description of Soil_. ---------------------------•-----•-----------••-----•--•----------------------------•---•--•-•--••---••--------•---------------------•-------•-----....-------------•-•--•••..............--••--•..... Nature of Repairs or Alteration — Answer when applicable_��!R.q.... .re. -x6... ..... Agreement: The undersigned agrees to install the aforedescribed Individual Sewage Disposal System in accordance with the provisions of'JI TL L 5 of the State Sanitary Code — The undersigned further agrees not to place the system in operation until a Certificate of Compliance h(s bpp&jtsued by the board of h%% h.. Signed. Application Approved Application Disapproved for Permit No...Q.O.'�©.d------------------------•--...... .......... --'' � ..�.._... _.. .. Date -------------------------------------------------------------......---................. Date Issued_. ..Q. //`` ----------------- ~ C/ l THE COMMONWEALTH OF MASSACHUSETTS BOARD OF HEALTH U: `{:........................... oF....t<;.: ::..:�:.' r i C C;,.J::t�` ....................... Tn tifirttfr of Tuutpliaurr THIS I-$ TO CERTIFY That the Indi.vidual Sewage Disposal System constructed ( ) or Repaired - (� by ----------------- 't- � ,�._._..� ? `--------•--•---------------.. •-------•------•-----------...---••-•--------------•----...--•-------------------..................... ! Ir4, +,_ . --•-- -- has been installed in accordance with the provisions of T� TTE 1� The State Sanita Code es 1b� $. the application for Disposal Works Construction Permit No, ...... dated._ . �l?�__..b_ .._.____... THE ISSUANCE OF THIS CERTIFICATE SHALL NOT BE CONSTRUE® AS f GUARANTEE THAT THE SYSTEM WILL FUNCTION SATISFACTORY. .... `......•....---•-------------- DATE --••-•-- = Inspector.._.. .....