HomeMy WebLinkAboutApp-Permit-ComplianceNoFi@B ..............................
THE COMMONWEALTH OF MASSACHUSETTS
__--BOARD OF HEALTH
—104)4) OF .......'..`--.......--•- .................... ...........................
........... I ............................... I/ I"
Appliration for Disposal Murks Tunstrurtion Vamit
Application is hereby made for a Permit to Construct or Repair _0<) an IndividuaP.l Sewage Disposal
System at: 07- //
CLO
.... F
�.l.�
... or Lot No.
0 tion' Address
...................... .. '.. i—� .. ... ..... ................. ..................................................................................................
W e Address
..................................................................................................
.....................................
-------- Installer Address
Type of Building Size Lot ............................ Sq. feet
Dwelling — No. of Bedrooms --------------------------------------------Expansion Attic Garbage Grinder
Other—Type of Building ------------- ...... No. of persons.._........._........__..... Showers Cafeteria
Otherfixtures ......................................................................................................................................................
Design Flow -------------------------------------------- gallons per person per day. Total daily flow -------------------------------------------- gallons.
4 Septic Tank —Liquid* capacity ............ gallons Length ................ Width....._..._..._.. Diameter-___-_-.-__--___ Depth.....__......._.
4
31 Disposal Trench — No- ------------------ 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
ate ----------------------------------------
Test Pit No. I ................minutes per inch Depth of Test Pit___.........._..._._ Depth to ground water .........................
Test Pit .................... Depth to ground water ........................
Test Pit No. 2 ................minutes per inch Depth of
.....................................................................................
Descriptionof Soil ------------------------------------------------------------------------------------------------
...........................................................................................................
....................................................................................................................... ...... en ----------
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 TIT TIE 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 the board of health.
---------------------- -
Date
By--& - -- - ---------------------------------- -------------------- Date
Application Approved ,�4 ----- r �--
Application Disapproved for% &AtD'�VgFons: --------------------------------------------------------------------------------------------------
Date
PermitNo --------------------------------------------------------- Issued --------------------------------------------------------
Date
THE COMMONWEALTH OF MASSACHUSETTS
130ARD OF HEALTH
................ J�'zl!V .... OF ........ y ...........................................................
Tntifira* aft-Omptiaurr
THIS.I,5 TO CERTIFY, That the Individual Sewage Disposal System constructed or Repaired (>Q
by---...... ....... ) In...... ................................. ....................................................................................................
�ler
A' .. ...... .............................................................................................
..... ..... . -------
has be installed �accordance with the provisions of,YI�T
,5 of State Sanitary Code as described in the
-----
application for Disposal Works Construction Permit No ..... ......... 1� �-- --
- - - dated___. ................
THE ISSUANCE OF THIS CERTIFICATE SHALL NOT BE CONSTRUED AS A GUARANTEE THAT THE
SYSTEM WILL FUNCTION SATISFACTORY.
DATE..--•...............................................•------------------------•-• Inspector,