HomeMy WebLinkAboutApp-Permit-CompliancegL.1 G1 FEs.......�..S............ _
THE COMMONWEALTH OF MASSACHUSETTS
BOARD OF HEALTH
.O F....../........................-------------------------------------- ..............
Applirtt#ion for Disposal Works Tonstrndion Prrmit
Application is hereby made for a Permit to Construct ( ) or Repair ( ) an Individual Sewage Disposal
System at: 1
................ .�._................. ................ ......................... .... -- -.... -- ---- ------•-------------...__.--_-------•------•.
Location - Addres or Lot No.
......................)---- -------------------------------------------------------------- .-_.---------..................
Owner ..._.. --....... Address
Installer Address
Type of Building Size Lot............................Sq. feet
Dwelling —No. of Bedrooms ............................................ Expansion Attic ( ) Garbage Grinder ( )
p, Other — Type of Building ............................ No. of persons ............................ Showers ( ) — Cafeteria ( )
Q'' Other fixtures ------------••---------•--------------------•-
Design Flow............................................gallons per person per day. Total daily flow ............................................ gallons.
Septic 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.
Z Other Distribution box ( ) Dosing tank ( )
Percolation Test Results Performed by----•-•--•-•--•-••.................••-••-----......----•----••---.....__ Date ........................................
aTest Pit No. 1................minutes per inch Depth of Test Pit .................... Depth to ground water ........................
(s, Test Pit No. 2 ................ minutes per inch Depth of Test Pit .................... Depth to ground water ........................
a............... ..................................................................................... ......................................................... i
ODescription of Soil ........................................................................................................................................................................
U� s
W. ----•-------------------------------------•------------------------------------------•...........•. ••-••---•••-•--�----- •-•--- 5
U 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 LITLL 5 of the State Sanitary Code — The undersigned further agrees not to place the system in
operation until a Certificate of Compliant een ' b t e a of iea
Signe.............
A .••................ ----------------.............
Application Approved By ...... -- ----- •.. ...-•-------•....................................... l-- --L-el-...._....
Date
Application Disapproved for the following re ns: ................................................................................................................
------•-'---•-------------------•-•...........-•••�•------••--•-------•----•--•------•-•--------••...............•--------------.._..••-•-----•--. • . .._.....Date--•---........
PermsNo.----- •--- ---------------------- Issued ----------•• -...............
Date
THE COMMONWEALTH OF MASSACHUSETTS
BOARD OF HEALTH
.......................................... O F .....................................................................................
Tatifiratr of &-int1diatta
TffIL IS TO CERTIFY, That the Individual Sewage Disposal System constructed ( ) or Repaired ( )
------------------------------
•----------------------------------
--------
•---------------------
by ------------------ ----.--•••-
Installer
--•
at ........ �1�c�C e ----�=--r- .. --
has been installed in accordant witli the provisions of TITLE 5 of The State Sanitary Code as described in the
application for Disposal Works Construction Permit No ----------------------------------------- dated ---------- :.....................................
THE ISSUANCE OF THIS CERTIFICATE SHALL NOT BE CONSTRUE® AS A GUARANTEE THAT THE
SYSTEM WILL FUNCTION SATISFACTORY. j ..
DATE....... .; a '' .......................................... Inspector r