HomeMy WebLinkAboutApp-Permit-ComplianceFm c.............�.....
THE COMMONWEALTH OF MASSACHUSETTS
BOARD OF HEALTH OLD M&P 3//O2Z
fi(/!"•-....... OF......... , �%� .�rL-"--•/%J' .......................... Na) M4P
Appliration for Di-opsFal Works Tons'tun autit
Application is hereby made for a Permit to Construct ( ) or Repair ( ) an Individual Sewage Disposal
System at:
r L n:.L=. .._....tC..' :_ :. -� = aT D Z _MOP..31.
...........
.........................................---••-----......
Location - Address or Lot No.
% r > r r
............. t5:_G:.oac.._..__..___..._......_..._...._......_.............._.._.........____........_....._............_.....
.r.
Owner - Address
Izr"-Ail_.6-f---`. eil-------------------------•- ----......�(l- ! :4! _.�i.:, .4" ..........................................
Installer Address
Type of Building Size Lot ............................ Sq. feet
Dwelling—No. of Bedrooms _______________e�........................ Expansion Attic ( ) Garbage Grinder ( )
Other — Type of Building ____________________________ No. of persons ............................ Showers ( ) — Cafeteria ( )
Otherfixtures-----•------------------------------------------------•-----•-------------------------------------------------------------------.._...:.......-------•
Design Flow ....... 3_ `1.0_______________________gallons per person per day. Total daily flow --______j 3__0 ...................... 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 ....................... /l_ v ................................... 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 ........................
Description of
--------------------------------------------------------------------------------------------------------------------------------------------- ------------------------------------------ --------
Nature of Repairs or Alterations — Answer when applicable ---------- 6 -: ✓ �2--------------..... -.�
Agreement:
The undersigned agrees to install the aforedescribed Individual Sewage Disposal System in accordance with
the provisions of TITI-E5 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...................................................................................... ................................
e
Application Approved By .................................................................................................. ........ �� t_------_..._
Date $
Application Disapproved for the following reasons- ----------------------------------------------------------------------------------------------------------------
..-•-•--•----------------•------------------------....-------.....------------------.._......-----......-•-----------------------•---------------- ------•------------------------------------....-----
Date
\ Permit No --------------------------------------------------------- Issued --------------------------------------------------------
Date
THE COMMONWEALTH OF MASSACHUSETTS
_ BOARD OF HEALTH
/.....OF ..... ...1/'rJ...Gf-7.................................
Trrtifirair of Tompliaurr
THIS IS TO CERTIFY, That the Individual Sewage Disposal System constructed ( ) or Repaired ( )
by----------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------
Installer
at----------------•-------------•--------•--------------------------------•---•------------------------- -----•-----------------•-----------------------•-•-•-------------------------------------------
has been installed in accordance with the provisions of TITLE 5 of,The State Sanitary Code as described in the
application for Disposal Works Construction Permit No..,�-`'//l;. �.----------- dated ................................................
THE ISSUANCE OF THIS CERTIFICATE SHALL NOT BE CONSTRUED AS A GUARANTEE THAT THE
SYSTEM WILL FUNCTION SATISFACTORY.
DATE----------------•
Inspector l--1
...........................................................