HomeMy WebLinkAboutApp-Permit-ComplianceNo...: .....
THE COMMONWEALTH OF MASSACHUSETTS
BOARD OF HEALTH
OF..................................... ....................................................
,�lir�tiott foriooal Works Tottorionrani#
Application is hereby made for a Permit to Construc ( ) or Repair an Individual Sewage Disposal
System at: G �� G
................... .. .......... ---..... -- --------- .d...... ....._ ..._........-'_-.... ..... .....
_. .......---
Location - r ss or Lot No.
. Owner Address
-- ... . ...........................................................
Installer Adddrdr
ess
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
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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 ----_------------------
Descriptionof Soil -----------------------------------------------------------------------------------------------------------------------------------------------------
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Nature of Repairs or Al erations — Answ r wapplicable- _=_/ - �.-- d
Agreement : �.
The undersigned agrees to install the aforedescribed Ind
ividttal Sewage Disposal System in accordance with
the provisions of TITLE 5 of the State Sanitary Code — The undersigued. further agrees n o place the system in
operation until a Certificate of Compliance h2 AEE!4 ted by t� boa of�l Rr-
Application Approved By !o
Application Disapproved �or the
Permit No. 9
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e
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----•-...--------• Date
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Date
Issued t� a A{
THE COMMONWEALTH OF MASSACHUSETTS
BOARD OF HEALTH
.......................................... OF .....................................................................................
Trr ifira tr of Tootpliattrr
THIS IS TO CERTIFY, That the dividual Sewage Disposal System constructed ( ) or Repaired
by---------------------�.� ..! _ . L ............/._�li:.rl'-f--�....---._ .....------. ------------------..............-------'---------------
y j InStall!r ' /,
at-_... L --- t�. � �'_%r _.5 � .3 r---------- - = . ..�-------------� '
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has been install in accordance with the provisions of TITIN 5 of The State ttam �qde s cr ed in the
1 i r_
application for Disposal Works Construction Permit No ....... '��_ ._._ dated __.�...............c.._.......—
THE ISSUANC OF THIS CERTIFICATE SHALL NOT.RE NSTRUED AS A GUARAN CHAT THE
SYSTEMA WIL , FUCTIO - ATISFACTORY.
DATE-----------=- --::;/0—'— --- -? z. ----------------------- Inspec --.