HomeMy WebLinkAboutApp-Permit-ComplianceNo. Fizz/ ......_i
THE COMMONWEALTH OF MASSACHUSETTS
BOARD OF HEALTH
OF................ .............. .------ ..........•----------------------------•.------------
,2� rlir i�an for Uhivovml igorkti Tontitrudion Frrutit
Application is hereby made for a Permit to Construct ( ) or Repair (A) an Individual Sewage Disposal
System at.. � or Lot �'I
.................
Location -Address '
...................... _.......................................................................... ..._........----•-............................--- -- ' - .._..._..... _....__...-
Address
W------------------ .-------
Installer Address
dType of Building Size Lot ----------------------------Sq. feet
U Dwelling —No. of Bedrooms---------------Ktank
------------------Ex ansion Attic ( ) Garbage Grinder ( )
aOther — Type of Building _-__•--------- ------------- o. of pers s_...__.....__....._.....___. Showers ( ) — Cafeteria ( )
04 Other fixtures --------------------------------------•-- _-----------------------------------------------------------•------•-----.---------------•----
d gallons.
W Design Flow----------------------------------•---------gallor person r day. Total daily flow__._...._______...----_•-------_-_-•- - •---
WSeptic Tank — Liquid capacity ............ galloLe ................ Width___---____------ Diameter ................ Depth _----__---_.--.-
x Disposal Trench — No- -------------------- Width ........__.._. Total Length..........._....._._ Total leaching area .................... sq. ft.
Seepage Pit No ..................... Diameter ..........._. epth below inlet...............__... Total leaching area .-•--------_-_--sq. ft.
Z Other Distribution box ( ) DotankPercolation TestResults Performed b--------------_----- •---------------------------------- DateTest Pit No. 1................minutes per inepth of Test Pi __ .._____..._____ Depth to ground water_____..____.______._.._.Test Pit No. 2________________minutes per inDepth of Test Pit-___----- ......... Depth to ground water ___---.-__---_-----__--_
•------•--•-•------•------•------•-•-••--•----••-------•--------•-•---------•-----••-----•.......... .........................................................
0 Description of Soil .................................................. ......................................................---•----------------•---------------------•------•-------------
x-------------•-----------------------------------------------------------•---- ...........................................
W---------- --------------------------------------------------------------------------------------------------------------------------------------------•----------------•-----------------...----•------
UNature of Repairs or Alter 'o s — An e hen applicable..__________ ______ -- _
----------------------•------------ ' •.--------•-•----- ••---------�----
Agreement :
The undersigned agrees to install the aforedescribed Individual Sewage Disposal System in accordance with
7 -
the provisions of 'TTLE, 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.
Signed........................ ............................................................ -----------•--
Application Approved By.
_t
Dat
Application Disapproved for the following reaso--•-------------------•---•-----------------------------------------------------------•--•----------•-•--------
Date
PermitNo --------------------------------------------------------Issued -- -
Date
THE COMMONWEALTH OF MASSACHUSETTS
BOARD OF HEALTH
.......................................... OF .....................................................................................
fit
Tatifiratr of Tomptiatta
THIS IS TO, CERTI , That the Individual Sewage Disposal System constructed ( ) or Repaired
by........................ . 1- -•-•-.•--- ----------•---•---.....--•-- ----- -•---•--------------•-----..__...----•---------------------------•-----------
Installer
at ................................ / =------ 2ee L�''
--------�../..............................................................................................................
has been installed in accordance with the provisions of TITLE j of The State Sanitary Co�je a-descr' ed in the
application for Disposal Works Construction Permit No ---- :__' _ -._7.__ dated_.-._______....! <: _..c1 .........
THE ISSUANCE OF THIS CERTIFICATE SHALL NOT BE CONSTRUED AS A U RAN E THAT THE
SYSTEM WILL UNCTION SATISFACTORY.
cam/
DATE ............. f/ d " . Inspector-- ... .. ------