HomeMy WebLinkAboutApp-Permit-ComplianceTHE COMMONWEALTH OF MASSACHUSETTS
BOARD OF HEALTH
.......... ----.....OF.......... ..................................
Appliration for Uispviial Works ToustrurtWu 1hrutit
Application is hereby made for a Permit to Construct or Repair � an Individual Sewage Disposal
system. at:
...................... ........................... .................................. .
. ................ .......
........ -Address s . .................. ..... ...... _/Av ........................
' dress
Installer Address
Type of Building Size Lot ............................ Sq. feet
Dwelling —No. of Bedrooms ............................................Expansion Attic Garbage Grinder (
Other—Type of Building ............................ No. of persons ............................ Showers Cafeteria (
Other fixtures ..................................................................................... ------
-e� -- ----------------------------------------------•-------
-------------- * ------ ------------- " -----------
------- gallons per person per day. Total daily flow ............................................gallons.
capacity/000gallons Length ................ Width ................ Diameter ................ Depth................
Des'
P—Liquid' 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 ........................................
�-4
Test Pit No. I ................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 ......................................................... .........................................................
0 Description of Soil .................................................................................................................................. ----------------.............--•-.---
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....................................
.........................................................................................................................................................................................................
................................................................................................................... . ............................... H.
I ... ; ,__..._....e ------------
ble ......... )= ......... A
1 r 10 —Answer Wwhn n applica
Nature of Repairs or Alt ti qs
ao
Agree2en�tolle- yo
The undersigned agrees to install the aforedescribed Individual Sewage Dispo?�salyystem in accordance with
the provisions of TIT: 5 of the State Sanitary Code — The undersigned further grees not to place the system in
operation until a Certificate of Compliance has en issued by thVb
,e of health.
Signed- ..... ... ..... . ... ......... . W_� ... ..... ........ .. .......... ------- �/_Rl/ - - ----
Date
...
te
. .. .. ...
Application Approved By .............................. ... ... . . ........... ........ ........... ie
Application Disapproved for the following reasons: ..............................................................................................................
..........................................................................................................................................................................................
..............
Date
Permit No-----------P-2i...
.-------------------------------
Date
THE COMMONWEALTH OF MASSACHUSETTS
BOARD OF HEALTH
....................... OF ........ I ........... : ................ '_4 .................................................
...................
Tntifirair of T-nutpliaurr
THIS IS -TO CERTIFY, That the Individual Sewage Djsposal System constructed or Repaired (4-7—
......................... ...................................................... . . ................................
by ......... ----------- ----------------- — --------- . ............... 7
Install
Z
at .... ................... `_� - --------------- I .......................................................................................... ....
. ...................
has been installed in accordance with the provisions of TITL' 5 o� The State Sanitary Code,as described in. the
application for Disposal Works Construction Permit No ..... ... ... ................. dated ...... .......... I ........
THE ISSUANCE OF THIS CERTIFICATE SHALL NOT BE CONSTRUED AS A GUARANTEE THAT THE
SYSTEM WILL FUNCTI" SATPFACTORY.
DATE .............................. ..................................................................................
.... ... 7 .. .............................. Inspector..