HomeMy WebLinkAboutApp-Permit-Compliance* No... .. . ...0
THE COMMONWEALTH OF MASSACHUSETTS
BOARD OF HEALTH 6LD p Ios�Gc�
( (? I S d No LLto .............. 0F..... t (t � r-�-........................................... NEW MPj
P� Appliration for Disposal Works Tomitrur#iou 1hrmit
Application is hereby made for a Permit to Construct (>e,) or Repair ( ) an Individual Sewage Disposal
System at
Lot Nom_
ocation Address
..=tit-----------------•----..........
- �NT.�!--�D ��.
r
��'v !--- ._.._..............----••• --• •-
� Owner�-
Address
----•------•----•-----.....--•--.............._..•...._........
..............................•---•---•--••---••----•---.........-----•..........................
Installer
y Type of Building
Address /
Size Lot_ ��,�. �..--.<-�_._....5 feet
q
Dwelling —No. of Bedrooms............ _ .._ . .Expansion Attic (
) Garbage Grinder ( )
a Other — T e of Building No. of persons ............................
Showers — Cafeteria
COther fixtures.-----•-----•---------------•-•-----------------•--•-•.---------..........--------------
Design Flow ............. _. .....................gallons per person per day. Total daily
----•--------••---•--........._._...........................
flow .......... ale ...................... gallons.
G Septic Tank —Liquid capacity.VM30.gallons
Length.... .� . Widtlij..�.._..
Diameter ................ Depth_____! -._.....
a Disposal Trench — No. ....... Width ------- 2_........ Total Length... z-��......... Total leaching area ... CIS .........sq. ft.
Seepage Pit No_____________________ Diameter....................
Depth below inlet....................
Total leaching area .................. sq. ft.
Other Distribution box ( ) Dosing tank ( )
q �l2�e,3
" Percolation Test Results Performed by"R�
F_A-VL *$LIQ ..................... .....................
Date._-- - .-.-----.----..........--.....
Test Pit No. 1...... 2 --..minutes per inch
Depth of Test Pit... ----
Depth to ground water..11,i9
y Test Pit No. 2................minutes per inch
Depth of Test Pit ....................
Depth to ground water ........................
• --• -------------------------------------••------•----------------------------------------------------------------
Descriptionof Soil ....... �o--------------------•--•-----•----------•------•----•-•---•-------------------------------------.-------------:..-----------------•-------------
----•-•----------------•------------------------.......------------.....-----------------•-••••......-•-•-•-----------......------------_..... _.........-•--------...--------------•---••-----•---------
------------------------------------------------------------------------•----------- •-----...... --••------------------------------------•--------------------------•._...---------------•---
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 TITIS 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.
Signed'.J.... _5�,r ' 3 ............
Date
Application Approved BY- - r.... .. ------ ....._' ...__....
Date
Application Disapproved for the following reasons: ................................................................................................................
-----------------•------••--•----------•-•--•-•--•-------•---------------.........------..--------•••---••--------•-•-----------...----------------------------........--•-----_..
Date
Permit No -------------------------- Issued: ........... - --sf
•-
..--- -•---•- Date ^................
THE COMMONWEALTH OF MASSACHUSETTS
BOARD OF HEALTH
O F ......
..:.:...........::.......................................................
Tntifiratr of TI-Intplittnrr
THIS IS TO CERTIFY, That the Individual Sewage Disposal System constructed ( or Repaired ( )
byf.�=-----------------------------•-----------------•-------•-------------- ------•-------- -
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 CO STRUE® AS A GUARANTEE TH THE
SYSTEM WILL FUNCTION TISFACTORY.
DATE/Lsp--------------------------