HomeMy WebLinkAboutApp-Permit-ComplianceNo1% Fzesl'-
THE COMMONWEALTH OF MASSACHUSETTS
BOARD OF HEALTH
...........................................0 F..:,�(........................--•--......................................
Auulutttuan for Disposal Works Tous�- ]Jhrmft
Application is hereby made for a Permit to Construct ( ) or Repair ( an Individual Sewage Disposal
System _ ... ... .... .......-------............... .... _...l,�.C`.....XIS... _....
........" ✓rLot No
.
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................. ......................
Address ...�..e-........................................ ,._ -..............»....
..ress ........ _................--------------
pq Installer Add
6 Type of Building Size Lot ................•--.........Sq. feet
I Dwelling — No. of Bedrooms---------------- -------------... ........ Expansion Attic ( ) Garbage Grinder ( )
aOther — Type of Building .............. ........... No. of persons ............................ Showers ( ) — Cafeteria ( )
dOther fixtures ................ ...............•----- --•••----••.•-••----•••--•••---•---•-•--•••....._..------•.._......-------•--•--••---------............----
WW Design Flow..........................................
1 s per son per day. Total daily flow -------------------------------------------- gallons.
W Se tic Tank — Li uid ca aci to en .__._ ... Width ............... Diameter.........._..... Depth ......•.........
P q capacity gth....:..
Disposal Trench No. idth._._............... Total Length.................... Total leaching area .................... sq. ft.
x po — .................
3 Seepage Pit No..................... Dia a r.............. .... Depth below inlet .................... Total leaching area ,................. sq. ft.
Z Other Distribution box ( ) Dosin tank ( )
~' Percolation Test Results ormed b......•.............................................. Date ........................................
,al Test Pit No. l................ ' utes per inch Depth of Test Pit .................... Depth to ground water ........................
Test Pit No. 2................ nutes per inch Depth of Test Pit .................... Depth to ground water ........................
a.............•-•----•----•-••--•--•..........-••----•-•--------•--........_.......--•-•...---------..........._............---------------------------- ---•-
0 Description of Soil ............................. <..........................................................................................................................................
",1
w ........---------•--•----------•------------ ----------------•---------------------
f f
U N tore of Repairs Alt do . s Answer n applicable�< -----------------!..--..__......----------------._........
. .� ��-^-----------------•-•--�-o------...-------•-------•-•-•-••••....._....----•.._.._..._.--•-.
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 been issuK
he bo d of health.
Signed -• -------•-----------•- 6 .. ._....
.
ApplicationApproved By............... _-----------•--•.........-----•---------......_...--'. --- .. .................
Application Disapproved for the fon asons:.........................................................................................................___
.....................................................••----...........-•---------------------'----------_.-...-----------------------------•------------..................................-•-•------------
.Date
3Stled.Permit No.S!'...........................-•-- - ....... -.......
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THE COMMONWEALTH OF MASSACHUSETTS
BOARD OF HEALTH
o
........OF..C'J!... ..Ar
J..��. .....f9rrtif it to of outrt
THIS IS TOC FY That the Ind' ' uaI Sewage,Disp al�Sj stem constructed ( ) or Repaired
$t.... _ ���\ ...... . Instal¢ !` �............... -- - ---- --
.....�`-
has been installed in accordance .with the provisions of TI LE of The State Samtar Code as de cribed in the
application for Disposal Works Construction Permit No._.:_ ............:.. datedYUARANTEE
itp_._ __.._:_......
THE ,ISSUANCE OF THIS CERTIFICATE SHALL NOT BE CONSTRUED AS , THAT THE
SYSTE WILL FUNCTION SATISFACTORY. --
QQ
DATE. . , . ..i,•. /9
................................................... Inspector ate' J21 ... 4 .....::t 4 .-... .: