HomeMy WebLinkAboutApp-Permit-Compliance,, ... 10q
No.-- ---:- y Fimic .... . ......
THE COMMONWEALTH OF MASSACHUSETTS
-� BOARD OF HEALTH
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.................. OF ........ YAA1hJ.b.fi_el_t.4-----------------------------------------------
Appliration for Disposal Works Tontrnrtion f rrntit
Application is hereby made for a Permit to Construct ( ) or Repair (/ an Individual Sewage •sposa-
System at:
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Location Address ---- or• Lot No.
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Owner Address
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AD.......................-._....... - .... - --- q .... ..._ kO D-x.__�_�1..---....W._y, ................
ap� Installer Address
6 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 ( )
a' Other fixtures.----------•---------------------------•---..._.....__.....-------------•---------------------------------------------._._..._..---•-•---•-•---•---_..
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Design Flow............................................gallons per person per day. Total daily flow ............................................ gallons.
Septic 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 ( )
'-� 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 ........................
x---------------------------------------------------------------------------------------------------• .........................................................
0 Description of Soil ........................................................................................................................................................................
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----•------------•-------•----•-------------------------•---------•----------------------------•----------•---------••-----•--------.................. ------
U Nat re of Repairs or Alterations — Answer wh n ap •cable_._____IQ�2_II_____G,¢4_---ZOAC--•Aj ..At�....... A.
..._...._..
C v r� We c -X� s_ �... S @�,ly l...................c. D� L
Agreement:
The undersigned agrees to install the aforedescribed Individual Sewage Disposal System in accordance with
the provisions of TIT1E 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 o�,eal'th.
Signed C.--��•�s�
Date
ApplicationApproved By ----- - ---- --- --- -•--------••............................................... .......
Application Disapproved f ollo i g reaso s: ------•--•-•--------•----•------••--•----------•-------------------••-----•--•----•-------•-----------••--------
...--------•---•--•-•--------•-----•--...-•---•-••---•-------•---•-----------------------------------._.....-----------------•--.--•--....---_.._---•-------_._._------•----. -
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�3 cifGDate
Permit No �.1_--- (........................................ Issued ................. ... ---��--..
ate
THE COMMONWEALTH OF MASSACHUSETTS
BOARD OF HEALTH
........ . .............. OF........Y/1'.f .lhA0x244..............................................
Tntifirtttr of Tomphaure
THI CERTIFY, Whitt the individual Sewage Disposal System constructed ( ) or Repaired
-by .............� .. Inx: - ----- L -•-------------•-----._.....-------------......_._.......----•-----.............---------------
-�r Installer
at1�' -.------•-------------•----------------------•---•.--...•-•---•--------..__....------...-----...._...•-•------
has been installed in accordance with the provisions of. TITLE 5 of The Sta e Sanitary Code as described in th
application for Disposal Works Construction Permit No ........ --_��__ dated----------- �����
THE ISSUANCE OF THIS CERTIFICATE SHALL NOT BE CONSTRUED AS A GUARANTEE THAT THE
SYSTEM WILL FUNCTION SATISFACTORY.
DATE.? ....... .? ..� OInsPect__00r- ---�-- - ----------------- ------ -------
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