HomeMy WebLinkAboutApp-Permit-ComplianceF:ms ..............................
THE COMMONWEALTH OF MASSACHUSETTS
BOARD OF HEA T,
Appliratiou for lliipo ial Worko Tottotrur#iott Frrutit
Application is hereby made for a Permit to Construct ( ) or Repair (4an Individual Sewage Disposal
System at
��Location - re
ss
Installer
Type of Building
Dwelling — No.
Other —Type c
Other
L—OT - N �I rrn,a-P - S a
............... . -... - .._............._
or Lot No.
Arlrlre�s
Ad/e.;r
Size Lot_ ......................... Sq. feet
of Bedrooms............................................Expansion Attic ( ) Garbage Grinder ( )
Building -------------_---_ - _.-- No. of persons ......................... ... Showers ( ) — Cafeteria ( )
fixtures .._
Design Flow ................................
Septic Tank —Liquid capacity.
Disposal Trench — No ..............
---------------------------------------------------•----•--.......•---•-_..
.__.gallons per person per day. Total daily flow -------------------------------------------- gallons.
__-gallons Length ................ Width ................ Diameter ---------------- Depth ................
Width .................... Total Length .................... Total leaching area .................... sq. ft.
Seepage Pit No --------------------- Diameter .................... Depth below inlet .................... Total leaching area .................. sq. ft.
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_______ __ ______ ____t........._�t_.....__._..._...__._..........................
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 issued by e board of bealth
00
Date
Application Approved By_________________
Date
Application Disapproved for the following reasons:
PermitNo .........................................................
---------------------
-Date
Issued---------------------- .................................
Date
THE COMMONWEALTH OF MASSACHUSETTS
�,r..._._ BOARD OF HEALTH
................... OF.....r��r 14...v...----.................--•---•--...
dw
Tutif rtt#r of Toutpliattrr
T S I O TIFY, T the Individual Sewage Disposal System cons ructed—( ) or Repaired (�
er
at �r/ �� , v%� Instalh.. ...... -----------------------------------------
has been installed in accordance with the provisions TITLE 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 CONSTRUE® AS A GUARANTEE THAT THE
SYSTEM WILL FUNCTION SATISFACTORY. �/L` L � � � � c
C
DATE C7Inspector--............................................