HomeMy WebLinkAboutApp-Permit-ComplianceNo.�V. _//� . Fns....
THE COMMONWEALTH OF MASSACHUSETTS
BOARD OF HEALTH
rC.u�.......... oF........
%'J--------------------------------------------
Appliration for D44putittl Works Towitrnr#inn Vamit
Application is hereby made for a Permit to Construct ( ) or Repair
((„� an Individual Sewage Disposal
System at
......�1......_.'�f� r..H.......... 514 ............ S .....'!�1 .....-----
- C" - c--- � ..Mme'- ...........
- ocation:-Address ---------------
.....-'--'-"------------------------------- -----------------------------------------------------
-
----•------•--- ---------
or. Lot No.
-----........_..._..............................---
�
Address
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-----------4-L -------------------------------------------------------
--------------------------------------•------------•----'-----------------'---....------'-•"•---------------------------------•----
--------
-------- --------------------------------------------_------------
•-'---•---•-•-•---•-----------....._..................-----...--•-
--------------------------------------------------------------------------------------------------------------------------------------------- --- ------------------------------------------------
Nature of Repairs or Alterations —Answer when_______________________________.
---------------------------------- .......-• .r�� .. ,� d�'�.�
Agreement :
The undersigned agrees to install the aforedescribed Individual Sewage Disposal, System in accordance with
the provisions of TITLE 5 of the State Sanitary Code — The undersigned further agrees not to place the system in
operation until a Certificate of Compliance has beef issued by th,p boa j of ji�lth.
Application Approved
Application Disapproved for the following reasons:
PermitNo .... _._ -. W. --------------------------------
D= ............
Date
Issued ...1. �4 Date ------
Date
THE COMMONWEALTH OF MASSACHUSETTS
BOARD OF HEALTH
O F. i� %` ""'',✓ ` �+ ,..... rte,
Trr#ifiratr of Toutpliatme
TyIS TO CERTIFY Thae the Individual Sewage Disposal System constructed ( ) or Repaired
by........ [ ...................................... 1 ......._.._......_..__.._...._.__............._..._._...... .........
r Installgrfl ` f
at�lC/d'
----- -r--- ----- L/,� -' �� e / ,?
- ---------------------------------------------------------------------------------------------------
has been installed in accordance with the provisions of TITLE 5 of he State Sanitary Code as described in the
application for Disposal Works Construction Permit No ..... ._.-.. _ _________________ dated.__.___=_ /l'__: _._..........
THE ISSUANCE OF THIS CERTIFICATE SHALL NOT BE ONSTRUED AS A GUARANTEE THAT THE
SYSTEM WILL FUNCTION SATISFACTORY.
DATE ................ ._ d...^ ............................... Inspector------