HomeMy WebLinkAboutApp-Permit-Complianceqo --cel-1 � � -�
THE COMMONWEALTH OF MASSACHUSETTS
BOARD OF HEALTH �uf
rwV1iNlWi
Appliration for Disposal Works Tonsirnrxion 1hrntit
Application is hereby made for a Permit to Construct ( or Repair ( ) an Individual Sewage Disposal
System at:SS
ocation - Address or Lot No. -
.......................................
— j
.........?'... a ..0 :............••.....................•-- . ------•--•-------------•---•---•-------._..... ._....------................................--
.Owner Address
999$------•---.------•-•-------•-----------------•-----------------------------------•--------.---------------------------------- -----------------------------------------••---
a= Installer Address
Type of Buildingj Size Lot ............................Sq. feet
Dwelling —No. of Bedrooms...........................................Expansion Attic ( ) Garbage Grinder ( )
Other — Type of Building ............................ No. of persons ............................ Showers ( ) — Cafeteria ( )
Otherfixtures -------------•--...------------------.....-----------.......--------•---------------------•-------._.....-----
Design Flow ............. 55....................... gallons per person per day. Total daily flow ............. b.0 ........................ gallons.
Septic Tank — Liquid capacityJ2�?.gallon Length... L.:-__ Width..' � `...__ Diameter ..............•. Depth -_g 'O"....
Disposal Trench — No ..................... Width .................... Total Length .................... Total leaching area .................... sq. ft.
Seepage Pit No._.___. _ ` >: � +�
pag ............ Diameter..... 1.b-.____.._.. Depth below inlet -_C. ............. Total leaching area.:�_.1. ?..sq7
,Other Distribution box (A) Dosing tank ( ) �r
Percolation Test Results Performed by ..... �� u=_. '�� t., L ................................ Date.. G':__L L : t-
Test Pit No. 1.!:_ . per inch Depth of Test Pit... N,:! ......... Depth to ground water_. ti?a'�:�L.._...._.
Test Pit No. 2................minutes per inch Depth of Test Pit .................... Depth to ground water ........................
......... �-------------,-------•-••------- •------- - ....... ---
Descriptionof Soil ....... \----•------------------------•---•-------------------------------............--•------......._.....------------.....
•--------------------------------------------------------------------------------------------------------------------•------------------------------.....-----...---------------------------------------
Nature 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 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..-- •- ...... --- /#d.. - - ............................... --- � �c17.-_----
Application Approved By-----------•--•--------------------- --- ------------ -a .........................................
�_._..
Date
Application Disapproved for the following reasons: ........................................................................................................
.....................•--------------------...--------------......--------------------------------...----.------------------........._.....-------------------------------------------------•....,
Permit No q0 ----q .. ............................. Issued.--- 5---- 2� 0... ate
Date .... .......
THE COMMONWEALTH OF MASSACHUSETTS
�1 BOARD OF HEALTH 1
..OF..............................
Trrtifirate of Tomplittnrr
TM, S O CERTIFY That th Ilaridual Sewage Disposal System constructed or Repairedby ( )
..
� ��/+� -taller
at--•--'t..&...•�.-•-•----•---...c�.... �-_------_---------- -------------------•--•----------------------•-------------••---•--------------
has been installed in accordance with the provisions of TITLE 5 of ThState Sanitary Code as described in the
application for Disposal Works Construction Permit No ----- ...--..... dated ...... rS .Z_r_1.6.....
THE ISSUANCE OF THIS CERTIFICATE SHALL NOT BE CONSTRUED AS A GUARANTEE THAT THE
SYSTEMA WILL FUNCTION SATISFACTORY.
DATE................................................................................ Inspector ....................................................................................