HomeMy WebLinkAboutApp-Permit-ComplianceN2yo--..... a K
THE COMMONWEALTH OF MASSACHUSETTS
BOARD OF HEALTH
............... ......_.....------------_.OF....1`�....�.�.................................................... ------•
, pplira#ion for Dispnaal Works Tomiiorrutit
Application is hereby made for a Permit to Construct ( ) or Repair an Individual Sewage Disposal
System at:
Ilocation - Addreys or Lot No.
r__-----____ = Lt'.✓..1� dre
Installer Address
Type of Building Size Lot ............................ Sq. feet
Dwelling —No. of Bedrooms ..................... ....................Expansion Attic ( ) Garbage Grinder ( )
Other — Type of Building ........................... No. of persons ............................ Showers ( ) — Cafeteria ( )
Oth fi t
erx ures-------------- ----------------------------------- ---------•----------•-----------.......--------•----------------------------------------•------
Design Flow__________________________________________ allons r person per day. Total daily flow ........................... _................ gallons.
Septic Tank —Liquid capacity .......... a
Length ................ Width ................ Diameter ................ Depth ................
Disposal Trench — No .....................
idth...... ............. Total Length ....................
Total leaching area .................... sq. ft.
Seepage Pit No .....................
Diame ...........
_. Depth below inlet .................... Total leaching area .................. sq. ft.
Other Distribution box ( )
Dosing t nk ( )
Percolation Test Results
Perf med by-----
----------------------------------------------•--------•-------
Date ----------------------------------------
Test Pit No. 1 .... _-----------
minutes per inch
De th of Test Pit ....................
Depth to ground water --___________-_------__.
Test Pit No. 2................minutes
per inch
De th of Test Pit ....................
Depth to ground water ........................
Description of Soil..
---------------_._-__-__-___-----.___-_---__-__-_---_------_-__-__-__-_-_----_---------..---_-----____.----------------------------_---_ + -----
Nature of Repairs or Alterations — Answer when applicable/ ..�-j./b_Z_ _.___;_./.......... ........... .•-
---------------------------------------------------- ---------------------------------------------------------------------------------------------------------------------------------------------------
Agreement :
The undersigned agrees to install the aforedescribed Individual Sewage Disposal System in accordance with
T r1' ^
the provisions of ("1T of the State Sanitary Code — The undersigned further agrees not to place the system in
operation until a, Certificate of Compliance has been j3e by thpoar health.
�/ ou t r
Signedeffftcr"'------------------------------------------- -�1n
at
Application Approved By ...................................
Application Disapproved for the following reasons: ..................
-----------------------------------------------------------------------------------------------------•--- .
Permit N
Date
Date
Issued_.......................................................
Date
THE COMMONWEALTH OF MASSACHUSETTS
BOARD OF HEALTH
.......................................... O F`...............................................................
All, tr of (fin mpliattrr
THIS IS URTIZY, That theTzdividual Sewage Disposal System constructed ( ) or Repaired ( )
bY------------------------ f- -- L........ Z7....... .. ------------ ------ ----------------------•-----------------------•------•------•-----------------•---------••------
In kker
at------... ........ X/ .----- 1. *'__: ! .I------------ � ------------------------------------------------------------------------
has been installed in accordance with therovisions of TIT r' j of The _ State Sanitary Code s , des ibed in the
P Y
application for Disposal Works Construction Permit No-___ _. __.,.�._____.__ dated.--.-% ..� _ ��_._.__-__._.
THE ISSUANCE OF THIS CERTIFICATE SHALL NOT BE CONSTRUED AS A G RAN EE THAT THE
SYSTEM WILL FUNCTION SATISFACTORY.
DATE................................................................................ Inspector -------------------------------------------------------------------------------------