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HomeMy WebLinkAboutApp-Permit-ComplianceFiFc ...... THE COMMONWEALTH OF MASSACHUSETTS BOARD OF HE TH ......... �Gt/-/t/...---.....OF......... Appliration for R-sposal Workii Tonotrurtion 1hrntit Application is hereby made for a Permit o Construct ( ) or Repair (3 -<an Individual Sewage Disposal System at� ..//....... s ...�L�. .............. ....��-�--..�: --- Ma ._._....... - --- - - ....t..�C f k oration -Address / / / or Lot 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 ........................ Description of Soil .................................... -----•-•---•------------------------•-•-------•-•------•----•--------------.....--•-------•--• .... ...__.._.------------------------ Nature of Repairs or Alt rations — Answer when applica.b1�. P�et!.rl ,'�--- � •G�c ism? .+ �.. -r1 .� /,Pk .................................................. ........................................------------------............ Agreement: The undersigned agrees to install the aforedescribed the provisions of TITLE 5 of the State Sanitary Code operation until a Certificate of Compliance has been i Application Approved By_ Application Disapproved for the following reasons:...........1... Permit No.------ �1=/.-----------.•---------------- Sewage Disposal System in accordance with nue , furer agre , not to place the stem in Date ------------------- ..... '�.—%5�1...--------- Date Date Issued.._._.. .............. Date THE COMMONWEALTH OF MASSACHUSETTS BOARD 9F HEAVfi ©�.................. OF ...... . ....................... .............................................. (In of iratr of Toutplinnrr THJS CERTYI%t t}e Iduo Sewage Disposal System constructed ( ) or Repaired by....../..SX! LSI.Z1� ...�3,_Z ------- at---- //...... �f%1�........................•---•---•--------------•--•---------------•----••------........ has been installed in accordance with the p�Rmit ons of TITLw 5 of The State Sanitary Code as described in the application for Disposal Works Cons tructio No ...... l_ _! ...................... dated -------- ............. THE ISSUANCE OF THIS CERTIFICATE SHALL NOT BE CONSTRUE® AS A GUARANTEE THAT THE SYSTEM WILL FUNCTION SATISFACTORY. ... ................ DATE.1 iInspector-----zi---