HomeMy WebLinkAboutApp-Permit-ComplianceTHE COMMONWEALTH OF MASSACHUSETTS
_DOARD OF HEALTH
®L ..OF ....... yo. 0.0 7 r7/ ..............................
................. 7
Appliration for Disposal Works Toustrurtion rrrmit
Application is hereby made for a Permit to Construct X or Repair an Individual Sewage Disposal
System at: -52-
0 12,;L_1 ....... ,sr . .. .......................... 1.0-7 . ... ............ . .
.......... ... . ..........
Location- o.
or Lot N
0 Add
0 .................................................
...................... . .. .................................................
Address
........................... Z5.;!ef e2M .... ......... ..................................................................................................
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/40.;*allons 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 ................ minutesperinch Depth of Test Pit____________________ Depth to ground water__-___.___._-.._.____...
Test Pit No. 2 ................ minutes per inch Depth of Test Pit__--___.....__--._.. Depth to ground water__-_______.._____.___--.
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Descriptionof Soil ............................................................................................................................................................
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Nature of Repairs or Alterations — Answer when applicable -----------------------------------------------------------------------------------------------
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Agreement:
The undersigned agrees to install the aforedescribed Individual Sewage Disposal System in accordance with
the provisions of T ITL 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.
igned------ ................................................................. ---------------
Da e
D
Application Approved BY ----•-- ........ ..... &.f...-- -----------•---___-___------ Date ....... /�
Application Disapproved for the following reasons: --------------------------------------------------------------------------------------------------------
........................................................................................................................................ .........................................................
Date
PermitNo ....................................................... . Issued .......................................................
Date
THE COMMONWEALTH OF MASSACHUSETTS
'BOARD OF HEALTH
.............. A aw..t . ...... 0 F ........ . . ...........................
Qlrrftfirai�vt Toutpliattrr
THIS IS TO CERTIFY, That the Individual Sewage Disposal System constructed (, ) or Repaired
by
Installer me
.........
at._...---- g�'�:; ......... ............. .......... ------- ----------------
..................................................
has been installed it,,
with the provisions of TITLE 5 of The State Sanitary Code as described in the
application for Disposal Works Construction dated ------
ii;xla ... / ............
T,
THE ISSUANCE OF THIS CERTIFICATE SHALL NOT BE CONSTRUED AS A GUARAN THAT THE
SYSTEM WILL FUNCTION SATISFACTORY.
DATE................................................................................ Inspector