HomeMy WebLinkAboutApp-Permit-ComplianceNo SSS--. ..... rte_
THE COMMONWEALTH OF MASSACHUSETTS
BOARD OF HEALTH
Zf........... OF....... ��1 /Me, �--------------------------------------
Applirtt#ion for Bispaattl Works Tnnstrnr#ion Permit
Application is hereby made for a Permit to Construct ( ) or Repair (,4 -)---an Individual Sewage Disposal
System at
eCA
L c o-�tlddress S k
j! ..•-----•------------•----------•- --------------------•---...--•----
Installer
Type of Building
Dwelling i�o. of Bedrooms ................. ........................ Expansion Attic
Other —Type of Building ............................ No. of persons........:..............
Other fixtures
or Lot No.
Address
.................................................
Address
Size Lot• ..........................Sq. fe
Garbage Grinder ( )
..... Showers )
-------------------------------------------------------------------------------------------•------------•---....._.........._.._.........--•---.......
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 Alterations — Answer when applicable.------ %____ �� ----- ( � ......._ 1�..........
--- --------------------------------•----•-------------------------------------•--..............---------------------------------------------------------------._.......------------------------...-----
Agreement :
The undersigned agrees to install the aforedescribed Individual Sewage Disposal System in accordance with
the provisions of TITLE 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 tke bo dalth. _
Signed_ �✓��.t5
--�--�----�--------j--
t
Application Approved BY/ES
Date
Application Disapproved for the following reasons----------------------------•-------•------------------------...-•-----------•--•-------------•----•----......._
Permit No..... . ...... ......---- ....-..--------------------
/ Date
Issued------------ -a` ). - .......
ate
THE COMMONWEALTH OF MASSACHUSETTS
�.._ BOARD OF HEALTH
.........�'`�'! ...... OF ........ ..............................
......
(Infifirtttr of f omplittnrr
TIJJS 1 0 TIFY T a he dividual Sewage Disposal System constructed ( ) or Repaired (�
by....- = - - ------ ------ - --------..._._ ......-----------------------------------------------.--------------
L�T_-'`� ..... .._._
f d+d �+••steer *� lr
has been installed in accordance with the provisions of TITLE 5 of The State Sanitary Code as described in the
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---------•..................................................................... . Inspector