HomeMy WebLinkAboutApp-Permit-ComplianceN0_2��! _(C) 1
THE COMMONWEALTH OF MASSACHUSETTS
BOARD OF OF .. . ........ HEATH
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Appliration for Disposal Works Tonstrit.rtion Itprmit
Application is hereby made for a Permit to Construct ( ) or Repair (�a.n Individual Sewage Disposal
System�t -•�� o r.. ........._ .... k°.5 ......... ..... ....-- •---...._............-._..
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Loc�tjaa -ess Cor Lot No.
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............. __ _L. ..� .........................................._�.�........---........_ ........................ __-__--
ner•-- Address
--!....�....................................•---_.........li�%tNl...----..............--•--•-----•--._.....-----....
Installer Address
Type of Building
Dwelling —No. of Bed
Other — Type of Build
Other fixtures
Design Flow ... 'ons
Septic Tank — Liquid ca. acity......... . 1
Disposal Trench — No . .................. idth ...
Seepage Pit No .................... Diamet ...........
Other Distribution box ) Do in
Percolation Test Result Pe rmed b ...
Test Pit No. 1 .............. ' utes per inch
Test Pit No. 2................minutes per inch
Size Lot ............................ Sq. feet
..............Expansion Attic ( ) Garbage Grinder ( )
o. of persons ............................ Showers ( ) — Cafeteria ( )
r 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........................
Descriptionof Soil.......................•--------••------•---............•.....----•----•----••••......--
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U Nature of Repairs or Alterations —Answer when applicable/a-r]'-f ............................................................. ..............
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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 b the rd of health.
Sign =............ �.................................................................--
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t
Application Approved BY ---•-#eoll
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Application Disapproved for t g reaso:---••.................•-••------••-•----•--------••-------....---•...................--•-.....ate-----•.---
.. 'Permit No....... -0.17 —11.! ..___....._��... ....... ..... Issued..........._. ..�/. �...... -
THE COMMONWEALTH OF MASSACHUSETTS
BOARD OF HEALTH
t
................. OF ......:�L...A .. �.......................................................
Trrtif irate of T antplinurr
THIS IS TOCE-RTIFY, T t the-Individual
� ual Sewage Disposal System constructed ( ) or Repaired c/
by.............................. ------....0 ..- - ._....:_.... --...............................................................-------•••------..........................._........
L n -
at.-•--- ...L7�. -•---• s•-• 4 ./1r�'��C�1 ��%...�
..._ ,. a-.__...----------•----------------._._.............._..._....-_.__._........_._
has been installed in accordance with the provisions of TITIN 5 of The State Sanitary Code as described in the
application for Disposal Works Construction Permit No.....2. 11. _.1.-L �................. dated ................................................
THE ISSUANCE OF THIS CERTIFICATE SHALL NOT BE CONSTRUED AS A GUARANTEE THAT THE
SYSTEM WILL FUNCTION SATISFACTORY. 7
DATE. �l2 l Inspector. !:� ' t r c� L
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