HomeMy WebLinkAboutApp-Permit-ComplianceNo. - Fizs..!
THE COMMONWEALTH OF MASSACHUSETTS
BOARD OF HEALTH
...O F ..........................................................................................
,� rlir ion
for Disposal Works TowUurfion ramit
Application is hereby made for a Permit to Construct ( ) or Repair an Individual Sewage Disposal
System at: \-,/
................_s.... �.....---......�1.... `/�u1� ........./_�/�=------..S.. -• --... :� N ..
K(ab
-------- -- --
Coca ]�Ap ress J /�
.......... .....{ [ cl r•� d.4 .� - c�/J /LJ—..........................................t---------------------------....- •--'
w er 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.
Septic Tank —Liquid capacity ............ gallons Length ................ Width._____-.--_--- Diameter ................ Depth ................
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 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 __________-------...____
Description of Soil
-------------•••---
--------------------------------------------------------------------------------------------------------------------X
-- ---- - ---- -------------------- - ----
Nature of Repairs or Alterations — Answer when applicable —____________ ------__-.___ .S
Agreement :
The undersigned agrees to install the aforedescribed Individual Sewage Disposal System in accordance with
'TTI
�•
the provisions of :f"I:.:�..� 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.
gl7ed/L. L<i L-; --•------------------------------------------------------- -------•----------------•-------
_',.,; C J A r� Date
Application Approved B -_------------ - �.. , - . f` =t_ ------------------
By ' Ys Lti . - cer Date
Application Disapproved for the following reasons- ----------------------•------------•------------ ---------------------------------------------•----------------
..------•-•-•-•----•--•-•----•------•---------•---------•--------••-•-•••-----------------•• ----------- -----------------------------------------------------------------------------------------------
Date
PermitNo --------------------------------------------------------- Issued .......................................................
Date
THE COMM-ONWEALTH OF MASSACHUSETTS
BOARD OF HEALTH
.......................................... OF .....................................................................................
%fit
luntifirFatr of TontpliFanv
THIS9, TO ; ER IFY, That the Individual Sewage Disposal System constructed ( ) or Repaired
by------------- .'. ................................................. i ---------------•--------------.....-•-------......-------•----•------------•-----•---------
at'-------•--------------------------------------
has been installed in accordance ith the provisions of TITLE > of The Ste�t�arlitary Code s de ribed in the
r r r
application for Disposal Works Construction Permit ------ dated__4�R
. _,l% ..��"'�.................
THE ISSUANCE OF THIS CERTIFICATE SHA NOT BE CONSTRUE® AS A TEE THAT THE
SYSTEM WILL FUNCTION SATISFACTORY.
DATE------------------------------------------------------------•------------------- Inspector