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Home My WebLink AboutApp-Permit-ComplianceNa ea::I, THE COMMONWEALTH OF MASSACHUSETTS BOARD OF HEALTH -•-------------------------------------OF....................................... AvOiration for Diaposal Vorkg Cnumitrurtion tirrmit Application is hereby made for a Permit to Construe System at: G Location - Addr ......�r _. Q�r�......_ r. q *--------------- Y� Owner Installer Construct ( ) or Repair (_X an Individual Sewage Disposal � ---•-- -k 13 ft or Lot No. Type of Building Dwelling —No. of Bedrooms........................:...................Expansion Attic Address Address Size Lot ---------------------------- Sq. feet Garbage Grinder ( ) Other — Type of Building ............................ No. of persons ............................ Showers ( ) — Cafeteria ( ) Other fixtures 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 ........................ ©�,...... .........•- -------••-•............... ---------- ..-•----.I Description of Soil -----------•---------------------•......-----------••-•---------•-•---•---------•-•-----•-----••--------•----•-------•------•----•--------•---•-----------•-•--•-•---•--•----• •--------- 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 TITI , 5 of the State Sanitary Code — The undersigned further agrees not to place the system in operation until a Certificate of Compliance has been i sued by the board of health. Signe---•- .s�___�J__-_.�-----------------•-----...-----•--------.. ......... ................. Date Application Approved B ' ate Application Disapproved for the following reasons-----------------------•-------------•------------------------------------•------------------------------------- Date ........................... •-•-•--- Date THE COMMONWEALTH OF MASSACHUSETTS BOARD OF HEALTH .......................................... OF .................. : ... * ....... .................. Tntifirate of f1 outpliattrr THIS I;S. TO.11FY, That the Individual Sewage Disposal System constructed ( ) or Repaired bY---------- ��...................•--- -----............................... ----------- { - Installer 1 - -- i has been installed in accordance` with the provisions of TITLE _5 of The State San ry Codo- a.aSles ribed in the application for Disposal Works Construction Permit No --------- ..-._ ._� % dated--- - �' }` �. 1 .:./._._.. THE ISSUANCE OF THIS CERTIFICATE SHALL NOT BE CONSTRUED AS A GUARANTEE THAT THE SYSTEM WILL FUN ON S TISFACTORY. DATE................. ................................ Inspector-------•----------� -----------....--....