HomeMy WebLinkAboutApp-Permit-ComplianceNo Fxs,i................
THE COMMONWEALTH OF MASSACHUSETTS
BOARD OF HEALTH
...................../o��� OF.....%t
Appliration for Biopnia1 Worko Tnnstrnrtionami#
Application is hereby made for a Permit to Construct, ) or Repair (� an Individual Sewage Disposal
System at: ��I�,J 5.93 �`���G zoitf )
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........ ................................................... �� .....- • -
Location dd e�sr or Lot No.
Owner � Address
-------------------------- -Alec-', --------- sJs..T+............-----------------........ -
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 ( )
Otherfixtures ......................................... -----------------------------•---------------.._....----•----------------------------------.....-•------•-•-
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 ........................
Descriptionof Soil------------------------------------------------------------------------------------------------------------------------------------------------------------------------
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Nature of Repairs or Alterations — Answer when applicable- -------- . _,l-------------------
Agreement:
__..-----._-_-_--.
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-----•---------•------•-------•------•---------------................................
Date
Application Approved B
PP PP Y �' `. Date
Application Disapproved for the el _V_40 &i&9----------------------------------------------------------------------------------------------------------------
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Date
PermitNo --------------------------------------------------------- Issued ....................................... ------•-------
Date
THE COMMONWEALTH OF MASSACHUSETTS
_ BOARD OF HEALTH
............ Z.......... a............... 0 F............................................................................
Trrt...L d#rIli (lint Batt!!
THIS IS TO CERTIFY; That the Individual Sewage Disposal System constructed ( ) or Repaired
bY............. :J.:_ a ---- - - . ...... . ---------------- ----------------------------...---•--------.......----•-•-----•-----....-----------•------.
T !Installer
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has been installed in accordance with the provisions of -_*Lw 5 of The S ate Sanitary Code as described in the
application for Disposal Works Construction Permit No.. `�:•: "___ M, *' ...... dated -427.-Z'
....... _f �-'_
THE ISSUANCE OF THIS CERTIFICATE SHALL NOT BE CONSTRUED AS A GUARANTEE THAT THE
SYSTEM WILL FUNCTION SATISFACTORY.
DATE................................................................................ Inspector.