HomeMy WebLinkAboutApp-Permit-ComplianceFizs...........
THE COMMONWEALTH OF MASSACHUSETTS
BOARD OF HEALTH
-----------------------------------------OF.....................
Appliration for Disposal Works Cfnnstrnrtion thrmit
Application is hereby made for a Permit to Construct ( or Repair ( ) an Individual Sewage Disposal
System at:
C�
Location -'Address leO��iZ C*gyp :57�6f Lot
N
....................... ......................'--------------.....-
o.
- .....
. ...--__•.....�J
ness 1
wi..... A
Installer / Address
Type of Building Size Lot_. _ C? ........ Sq. feet
Dwelling — No. of Bedrooms ...... ..��..................................Expansion Attic ( ) Garb ge Grinder ( )
Other — Type of Building ............................. No. of persons ...... _..................... Showers ( ) - Cafeteria ( )
Otherfixtures------------------------------------•------•----------....----------------------------------------•------------------......-----......----...---......
Design Flow ------------- `5_ ._....._.._.___._....__gallons per person er day. Total daily flow ----------- _....... ._.___gallons.
i
Septic Tank — Liquid capacity_s�gallons %ength................ Width../e/_s.._ Diameter ................ 3epth_,�..
Disposal Trench — No. _.Z .............. Width __.._l�__........... Total Length ......... �.,z�-.._.... Total leaching area ....
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 _ . Laiiinutes per inch Depth of Test Pit/ _ .. Depth toound w� ate .._152,5.. �_.
'n'
Test Pit No. 2................minutes per inch Depth of Test Pit .................... Depth to ground water .........................
Description of Soil____ ____ _____________ ----- '------_-_---------•-
-------------------------------------------------------------------------------------------------------------•------------------------- ...............................................................
Nature of Repairs or Alterations — Answer when applicable.....-. ............................................................................ 6 ............
------------------------------------------------------------------------------------------------•------------------------------------------------------•--------------•-----------------........._-•----
Agreement:
The undersigned agrees to install the aforedescribed Individual Sewage Disposal System in accordance with
the provisions of TITIN 5 of the State Sanitary Code — The undersigned further agrees not to place the system in
operation until a Certificate of Compliance has beery issued by the board o f 4-ieal i _ „ n
Application Approved By
CAA—......_t�- ?._��3 .
.......
04 Date
Application Disapproved for the follojWg reasonj ................................................. -•---------------- -•----•-----------•------•-----•---
-------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------
C Date
Permit No.------ .--�------------'-------------•---.. Issued_ /A y�- -------:
!Date
THE COMMONWEALTH OF MASSACHUSETTS
BOARD OF HEALTH
.......................................... OF ... .................................................................................
Tnrtifiratr of Toutpliattrr
THIS IS TO CERTIFY, That the Individual Sewage Disposal System constructed ( ) or Repaired ( )
by-----------------------------------------------------------------------------------------------------
Installer
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 No ..............._-___..._._------_._.__-. dated -----------_-----_--------- _---_-_._..------
THE ISSUANCE OF THIS CERTIFICATE SHALL N BE C NSTRU UARANT HAT THE
SYSTEM WILL FUN TIO ISFACTORY.
DATE........ Insp for ..... ........... --- •---- -------- .- - - - -- -- ...............