HomeMy WebLinkAboutApp-Permit-ComplianceNo. ---- -__t---_, l..
THE COMMONWEALTH OF MASSACHUSETTS
BOARQ F HEALTH
••-------.--.............-.�OF........................._............---------------._.._-•----.
Appliration for Disposal Works tion Prrutit
Application is hereby made for a Permit to Construct ( or Repan Individual Sew
System at:
------------------------------------------ 1_a -t' - X a� •-------- -----a=
-Location - Address or �I of No.
:5?-��....... lT .:. ....`2:�:� 4�.t.\�4 -----•-•-------------
- ---- ---------•------------------------
O er Address
Installer Address
Type of Building Size Lot__________________
Dwelling—No. of Bedrooms................Z.___._________.____.___Expansion Attic ( ) Garbage
Other —Type of Building ____________________________ No. of persons ............................ Showers ( ) — C
Otherfixtures ----------------•-- ----•-----.._...------------------.-••••------------•---------•---
Design Flow -------------------------------------------- gallons per person per day. Total daily flow .................................
_
Septic Tank — Liquid capacity_l�?Q_.0gallons Length ................ Width ................ Diameter________________ D
Disposal Trench — No_ ____________________ Width .................... Total Length .................... Total leaching area ......
Seepage Pit No --------------------- Diameter .................... Depth below inlet .................... Total leaching area_____
Other Distribution box ( ) Dosing tank ( )
Percolation Test Results Performed by__________________________________________________________________________ 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_
--•-------••----------------------•-------------...--•-----•-------....-------•----------•---------- ---•-----------------------------
Descriptionof Soil ........................................................................................... .....................................................
---------------------•----•-----------•--•-•--•-------------••-------•-------------......•---•----•----•-•------------------------------------....-----------------------------•
Nature of Repairs or Alterations — Answer when applicable.______�..................
age Disposal
.......................
.......... Sq. feet
Grinder ( )
afeteria ( )
.......................
........... gallons.
epth ................
.............. sq. ft.
.............. sq. ft.
.......................
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 1�eg�IYi�ss�u bw Ah oa d of health.
Date
Application Approved By
Date
Application Disapproved for the following hasohs_____________________________
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I --Date
Permit No ..... .-I_--..1..------•--------------- Issued ._.. !� 3� I_
ate
THE COMMONWEALTH OF MASSACHUSETTS
BOARD OF HEALTH
.......................................... OF .....................................................................................
TrrtifiraU of Tontplianrr
THIS IS TO ER IFY, That the Individual Sewage Disposal S7stem constructed ( ) or Repaired ( )
by............ ------•--•-----••--••----•.......-----•--------------•----•-•---•-------------•----...----------------....-----..... ---
Installer
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at -------------- ----C t .
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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_________________________________________ dated ................................................
THE ISSUANCE OF THIS CERTIFICATE SHALL NOT BE CONSTRUED AS A GUARANTEE THAT THE
SYSTEM WILL 37
� SATISFACTORY.
DATE. :.. Inspector... f