HomeMy WebLinkAboutApp-Permit-Compliance��7 .. %=�aV
..............
THE COMMONWEALTH OF MASSACHUSETTS
0 RD O HEALTH
lr�oF............... ...
. ppliratilan for Disposal Warks Ton,strurtuan lirrutit
Application is hereby made for a Permit to Construct (;` or Repair ( ) an Individual Sewage Disposal
System at,
..........:._............ .. .... 4?.--.----•..-.--•..--..._....._-_--..-•---.----.-•- --� ... ... _map
�aco
- ation -Address or Lot No. ,
............. ......... ^... ....................•'.. ---.._._._ -•--..............._._....._._........._...---
IN- Address
............. . n
_.,ey ...
Instal
t/
/Type of Building Size LAddress
ot............................ Sq. feet
�-, Dwelling —No. of Bedrooms ............................................ Expansion Attic ( ) Garbage Grinder ( )
aOther — Type of Building ____________________________ No. of persons ..... _...................... Showers ( ) — Cafeteria ( )
Other fixtures
W Design Flow ............................................ gallons per person per day. Total daily flow ............................................ gallons.
WSeptic Tank — Liquid capacity ............ gallons Length ................ Width ................ Diameter________________ Depth ................
x 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 ( )
�4 Percolation Test Results Performed by ................ --------------------------------------------------------- Date ........................................
Test Pit No. 1 ________________minutes per inch Depth of Test Pit________-___________ Depth to ground water ........................
fs, Test Pit No. 2 ................ minutes per inch Depth of Test Pit .................... Depth to ground water ........................
Description of Soil__________________
..--•------------------------• •---•-•--------------
•••••••••----•--•-----•••••••-••-•••••••-•-•••••••••-•••--•---••••••••••••-••••••-•••--...•-••••••-•---•-••••••••••-•---•••••-----•••••--••-•-••••-•••--•-•----••••-••••_____________________•----_____
i 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 TITLE 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.
Application Approved By.
Application Disapproved for the following reasons:..
PermitNo.........................................................
------
�
=--��----.--------
Date
- Date
Issued.......................................................
Date
THE COMMONWEALTH OF MASSACHUSETTS
�OARD OF HEALTH
.... ...:.....OF...... � �:'� ..............................................................
wrtutraw of (dant liana
THIS I,S 7 O CERTIFY, That the Individual Sewage Disposal System constructed (k) or Repaired ( )
,� Installer
atr.-u:.f._- = --------------------•-----------------------------------------•---•---•---------------
has been installed in accordance with the provision§ of TITIN, 5 of The State Sanitary Code as described i . the
application for Disposal Works Construction Permit No._ _ _.'----- ,17 ....... dated____
THE ISSUANCE OF THIS CERTIFICATE SHALL NOT BE CONSTRUE® AS A GUARANTEE THAT THE
SYSTEM WILL FYNCTION SATISFACTORY. j�
DATE. ` _ 7.,�..-•--------•----------------- Inspector<+..:N'L------- �/--✓`3:_..............................