HomeMy WebLinkAboutApp-Permit-ComplianceNoA-6—
THE COMMONWEALTH OF MASSACHUSETTS
BOARD OF HEALTH
............ OF .....
,rT✓.iY�OYI
Appliratiun for Biopuuttl Works Tonstrur#tun Errant
Application is hereby made for a Permit to Construct
System at
�` Location - Adgrgss
......................___.. Q............... ------.-._.---------------
Owner
Installer
) or Repair (k)- an Individual Sewage Disposal
toT
--- or Lob No.
...................�--- `'N` �----------- ........................... ........
Address
............ ---- r y ` S T ..................................
Address
Type of Building Size Lot ........................... Sq. feet
Dwelling —No. of Bedrooms...... c ..." _- ............................Expansion Attic ( ) Garbage Grinder ( )
Other — Type of Building ............................ No. of persons ............................ Showers( ) — Cafeteria ( )
Other fixtur......................... -----------------------•--.--•-----•------------------------------ ------------------------------------------------------
- -
Design Flow .............. ..................... gallons per person per day. Total daily flow.......�--0.................. 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 ..... /.D._...... Depth below inlet ..._q.r........ 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 ---------------_i.r0u---.----.(.........................................
-----------------------------------------•--•-------•--------------------------------------------••-----•----------- -•-----------------------------•------------....._...-••-•••----
ecic C�
Nature of Repairs or Alterations — Answer when applicable_._.._. ` ___._.`� Vic?..__. - ............... ......................
Agreement:
The undersigned agrees to install the aforedescribed Individual Sewage Disposal System in accordance with
the provisions of TITLF, 5 of the State Sanitary Code — The undersigned further agrees not to place the system in
operation until a Certificate of Complianc the botrd of
Sign t -
e
Application Approved BY::/:_:,:0Z = 1�1.-------. -
Date
Application Disapproved for the following reasons:---•-•-----•--•--•-------------•----...---••--•--•-•-----------•-•-•--•----------------••-------------......
Permit No .... --JI _-1-------------•---...-----
THE COMMONWEALTH OF
---------------------------------------------------------------------------------
Issued.---D�/�..... ._
ate
MASSACHUSETTS
BOARD OF HEALTH
C
J.". OF ..... J Y..1!! ' '. . ' �.............................
IntifiratrJ of Tantlrlittnre
idall Sewage Disposal System constructed ( ) or Repaired (,)
�.......................................................... --
',
Ins It
rovisions of TI rL��/ 5 ofrl_he State Sanitary Cod as escribed in the
Permit No. j�l ....---------- dated__..__. -7 .< �---- •-----------
",TE SHALL NOT BE CONSTRUED AS AGA "TEE THAT THE
tY.
Inspector ----- --=-•- --•--'---........