HomeMy WebLinkAboutApp-Permit-ComplianceI FEic.2&,5 . ...........
THE COMMONWEALTH OF MASSACHUSETTS
-� BOARD OF HEALTH
.�1.......... OF ........ ----•-----•...........................
Appliration for Uh4p tittl Works Tnnirnr#inn Permit
Application is hereby made for a Permit to Construct (tom or Repair ( ) an Individual Sewage Disposal
System at:
Location . Address or Lot No.
Owner Address
W....._...-•••--•........-••--•-----•---...••'--......-• ...........................................
Installer Address
Type of BuildingSize Lot ._%jz�_...... Sq. feet
Dwelling — No. of Bedrooms.....•.......-.�............................Expansion Attic ( ) Garbage Grinder ( )
PL4 Other — Type of Building ............................ No. of persons........................--.. Showers ( ) — Cafeteria ( )
P4Other fixtures ------------------•----•---•-•------........-•---.....------------------....-•---------•----•---_-_-------...
W Design Flow .............
............................... per person per day. Total daily flow......... ...................... gallons.
WSeptic Tank —Liquid capacity.Zo.P.P..gallons Length_ 8.� ''... Width..dt �� ,�.. Diameter ................ De th.: 5-&//.
x Disposal Trench — No.....,/ ............. Width...... - ........ Total Length.... l......_ Total leaching area... ZZZ4 ...... 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 .... 4-!:!✓Y!�...L ::..:�� 6-11 .............. Date..,r �-���_ S _ `z�...
aTest Pit No. 1. G. - ._.min t per inch Depth of Test Pit ... Z.3:Z'.._._ Depth to ground water..... a�_''.. --.
(i Test Pit No. 2................mind es per inch Depth of Test Pit .................... Depth to ground water ........................
•-••----------------------•---....-•------.......•...•...................._........•--•----•--••--• ............................................. •...........
O Description of Soil ...... !L 3`-'-"..k! c,"t-, L`' -a2- ----- Z_4z 4r..Z e:6 ---••-•-3` �- _ ZK............
...<-------------
U---••--........................................ /08" ...n/� Sl�iv��------•fvv /3 2-
U
�� y 4---51��i�
---- - -...... � %'f
W•-••••---------------------•-•----•••--•---•----•------••--•-••••••---•••••••--........._..•-•--•••----•-•---••-••-•••••----•-••-••••--••-••-----•••--•••---••--•------•-......--•-•-•-•.....---•--••_..
UNature 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 TITLE 5 of the State Sanitary Code — The undersigned further agrees not to place the system in
operation until a Certificate of Compliance has be ed b the ar �oh,
Signe ............. ....... -* 1 �»
- -••-.......... — Dat....... -
Application Approved By--•�1�..................................... ........................ . ;Z_ Date
Date
Application Disapproved for the f ollounng reasons---------------•-------•---------•--•---..........---....-•---................-----........ ••-----•--------- -
...............•••-• •-•------• • •••-----•----•-------••---•--------••------• •----•---....----••-------•--•.........._.........--•-----•--•----•-••-•--••-•-•--•----•-•••-•-----------------.......---_..._
Date
Permit No .... d
..--- ---y-------------------------- Issued ............ .�"'Z____D�r�_,�.,...._.�......
_y�
THE COMMONWEALTH OF MASSACHUSETTS
BOARD OF HEALTH
............��:�.!:!r..........OF.......... �`T.r�! 77-...1 .....................................
Tntif ira tr of Tompliatta
THIS IS TO CERTIFY, That the Individual Sewage Disposal System constructed L,,) -or Repaired ( )
n
/Installer
at--- �. � .... .
= ��
has been installed in accordance with the provisions of TIME 5 of The State Sanitary Code as described in the
application for Disposal Works Construction Permit No ..... Wil._ . ............... dated ....--.2--_ _ ..... L1- ............
THE ISSUANCE OF THIS CERTIFICATE SHALL NOT BE CONSTRUED AS A GUARANTEE THAT THE
SYSTEIaI WILL FUNCTION SATISFACTORY.
Inspector------- --------
DATE------. —. s�Q... _{- .---------------=----------------------------