HomeMy WebLinkAboutApp-Permit-Compliance..........................
THE COMMONWEALTH OF MASSACHUSETTS
BOARD OF �H,, EEALTH
•---------1-0''�A-----------------OF....... - ►�"!"` `•.' ---------..._...........__.---------------------
Appliration for Bispaoal Warks Tontitrurtum ramit
Application is hereby made for a Permit to Construct ( k) or Repair ( ) an Individual Sewage Disposal
System at: ,E'7 j1.(cc
__
Location - Address _ or Lot No. .
Owner Address
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Installer Address
Type of Building Size Lot..,_fl_Td`_4�... Sq. feet
Dwelling — No. of Bedrooms ........... z- ...........................Expansion Attic ( ) Garbage Grinder ( )
% Other — Type of Building ............................ No. of persons ............................ Showers ( ) — Cafeteria (
Otherfixtures -------•--------_-- ---------•-----------------•----.•---•••••-•-•--••--•---•-••••-•-•-••-------•-••-•-•...---------•--------.................••--•-
Design Flow .............. J`^._.................._.__gallons per person per day. Total daily flow ._ZrX,\c7._=_-ZZsJ_...
lons.
Septic Tank — Liquid capacity!Px allons Length--- Width__'1'.!v��. Diameter________________ Depth ----1?_.__.
Disposal Trench —No. ...... i............. Width .....fit`......... Total Length ....��....... Total leaching area --- s3Se----sq. ft.
Seepage Pit No ..................... Diameter .................... Depth below inlet.................... Total leaching area .................. sq. ft.
Other Distribution box (X) Dosing tank ( ),1
Percolation Test Results Performed by ..... -._._4��1?!-------------------------------------- Date...Z-16��'� .............
Test Pit No. 1. .!�.Z-....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-_____-_-__..._..--.____
-----------------------•---•
x-•----------•-----------•........--••-•--------------------•-----....--- .........................................................
O Description of Soil ........................ -!.. ..
W
U---------------------------------------------
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••.........••-
... ----------------------------------------•-----•------------------------------•--------------------•-------------
W-•-•---•----•---------------•-•-••---•--••-••-•-•----------•------... --•-•--•--•-------....------••------•••--•----------------•----••-------•----••--•--•---•--•-•--•-•---------------•-----•---------
VNature of Repairs or Alterations — Answer when applicable ------------------------ .......................................................................
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Agreement :
The undersigned agrees to install the aforedescribed Individual Sewage Disposal System in accordance with
the provisions of TITLE 5 of the State Sanitary — Thgun ersigned further agrees not to place the system in
operation until a Certificate of Compliance has be ssu byoar
of health.
,r
Signed ` v..y"- e
D .
Application Approved By---- L!5.�. � �' J Date
Date
Application Disapproved for the following reasons---------------------•-----------------------------------------------------------•--------------------...........
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Date
Permit No......6.5----- Issued_..................I J. -t3 .
Date
THE COMMONWEALTH OF MASSACHUSETTS
BOARD OF HEALTH
.......................................... OF .....................................................................................
Trr$ifiratr of T.untpliatta
THIS IS TO CERTIFY, That the Individual Sewage Disposal System constructed (y�i ) or Repaired ( )
byr `.=> �:_4.:.,•r• —-------------------------------------------------------------------------------------------------------------------------------------------------------------
Installer
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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.:;=., -.__:_J--- -- ------------------ datedQ_/__.._� __f..
THE ISSUANCE OF THIS CERTIFICATE SHALL NOT BE CONSTRUED AS A GUARANTEE THAT THE
SYSTEM WILLFU TIQd� S TISFACTORY.
DATE....._,.zz ` ....'-•------------------•-•-----••---_.. Insp ------
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