HomeMy WebLinkAboutApp-Permit-Compliance-�.. .....� Fps.. ,j�...`...
Nus �
THE COMMONWEALTH OF MASSACHUSETTS
,BOARD OF HEALTH
........ 166. �.... OF .......... r Cil ...................................
Appliration for Disposal Worko Tonatrnr#ion Vamit
Application is hereby made for a Permit to Construct (Jj or Repair ( ) an Individual Sewage Disposal
System at :✓ �i1 U �,�-
- - Location - ries or Lot No.
- .... � ..: I.-----------------•'----......-----------------------------...---......
Owner Address
............................ .� W. .--------.......---•---•--.....---------••-------......
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. I................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.......................................................................
-•---------•-------•--------•--------------------•-------------•--•-•--------------------------.....--------...--------------------------------•-------•---------•-•-------------------------------.....
Agreement:
The undersigned agrees to install the aforedescribed Individual Sewage Disposal System in accordance with
the provisions of TITTIL 5 of the State Sanitary Code — The undersigned further agrees not to place the system in
operation until a Certificate of Compliance has been is by the board of health
j9Kr n _
Application Approved By
Application Disapproved for the following reasons: ___
----------------------
Date
PermitNo --------------------------------------------------------- Issued --------------------------------------- -----------.-•--
Date
THE COMMONWEALTH OF MASSACHUSETTS
_ j�ByryOARD fOF HEALTH
..................>.'......xSa..l.Gf...OF......'.f..:::.FrEr''.w..../.�Y....................................
TrrtifiraU of Tomptianr
THIS IS TO. CWIFY,, That the Individual Sewage Disposal System constructed (. or Repaired ( )
4 .r s
r
a Ir}sta�ler�
- 1 '
at--•---..:!� ._. ' = . �. ,.rid f' °' ✓ "' ' ------------------------ --------------------•-----•-------------
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.441-I-'�..d __..... dated__ ",r -1- ,(�----------------
THE ISSUANCE OF THIS CERTIFICATE SHA LLT BE CONSTRUED AS A GUARANTEE THAT THE
SYSTEM WILL FUNCTION SATISFACTORY.
DATE............................................ .................................. Inspector.