HomeMy WebLinkAboutApp-Permit-ComplianceFu$ eet"; ..
THE COMMONWEALTH OF MASSACHUSETTS
BOARD OF HEALTH
BOARD
----.-...:. W 0----------------OF......V.NfR_ ,ac 1 ._......._.........._....
Appliratiott for Disposal Works Tonstrudion 1rrutit
Application is hereby made for a Permit to Construct (>\) or Repair ( ) an Individual Sewage Disposal
System at
n �
� ��"� •••..........._ �?. .Z: ..rr .�:l.X�,QJ_ ?_.` 1�...... ..We,S I. R��lwo.a`l..l*-------
Location - Add e /
,rR-t� or X
..._...----• ---•....... - ---••-- --------^--- -------- i..._.._._ _................................Owner-1A
Installer Address
Type of Building Size Lot ---- 1�_sr?ta......Sq. feet
Dwelling —No. of Bedrooms ..__.._. 3
..............................Expansion Attic ( ) Garbage Grinder ( )
Other — Type of Building - X111 Il... No. of persons ............................ Showers ( ) — Cafeteria ( )
Otherfixtures ........... \ t_ �M.Ue.cJ............................-------•----...........................................................................
Design Flow ................. 5.x..2_ .................. gallons per person per day. Total
.- dail fl
ow....... 3_Q--------.-.---------- - gallons.
Septic Tank—Liquid ca acit-l-OOD._ allons Len h.,1�----- Width:.ZZ..,tDiameter:............... Depth.. --f
Disposal Trench — No...__....7.......... Width ..... Z....__.__..
Total Length.?0.xi—S Total leaching area.Z.W. .........sq. ft.
Seepage Pit No ..................... Diameter .................... Depth below inlet .................... Total leaching area .................. sq. ft.
Other Distribution box ( ) Dosing tank ( )
Percolation Test Results Performed i.......•.......•........... Date. -L� �_1 ...............
Test Pit No. 1................minutes per inch Depth of Test Pit ......(P...._. 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. ................ ......................
- --- - ---- ------------------------------------•--------•--.....---------.......-----•--..........------..................-•-•••-•-••-•---•-•..........
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 is edAj the_bDaF4ofd lth.
Application Approved
Application Disapproved for the following reasons:._..
Permit---------------------•---
....Date �-
......— --=--------
Da e
— Date
Issued. ----------- _,...-',:................. -
Date
THE COMMONWEALTH OF MASSACHUSETTS
BOARD OF HEALTH
Trr#ifiratr of TootPluturr
THIS IS TO CERTIFY, That the Individual Sewage Disposal System constructed (r•') or Repaired ( )
by
. Installer w
at..... ............................
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............. dated..... .................
THEASSUANCE OF THIS CERTIFICATE SHALL NOT BE -CONSTRUED AS -A GUARANTEE• -'THAT THE
SYSTEM WILL FUNCTION SATISRACT.O�RY, a , - � ' ,f
............... .. Inspector - _ "" /` ` _'.. _ .............r =.......