HomeMy WebLinkAboutApp-Permit-Compliance/ f
No
THE COMMONWEALTH OF MASSACHUSETTS
/BOA AD . ...E HEALTH
%J ..li�..................
......_.....----------•-----
OF ..
App ration for Uiipnsal Works Tonstrnrtion ramit
Application is hereby made for a Permit to Construct ( ) or Repair ( t_�'an Individual Sewage Disposal
System at _ L–) _ � , 1 Qn
,(,
Installer
Type of Building
Dwelling — No. of Bedrooms .........
Other — Type of Building _...........
6Y_ l l
--•. or Lot No.
R 1 (-�........ ............... �..... �......--r........... ._......_..-
-dre
-------------------------------------
Add ess
Size Lot ---------------------------- Sq. feet
...............................Expansion Attic ( ) Garbage Grinder ( )
............ 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 ........................
Descriptionof Soil------------------------------------------------------------------------------------------------------------------------------------------------------------------------
---•-----•-------------------------------•----------•-----------..................................................... ........................................................
•-...--------------------
--------------------------------------------------------------------------------------------------------------- ---�-i yyrr - ---- --
Nature o Repairs orAlterations —Answer when applicable.----- --------- _ _... . _- r 7 --1- --......-66 nlz_
-------------- ------------------------------------------------------------------------------------------------------------------------------------------------------------
Agreement :
The undersigned agrees to install the aforedescribed Individual Sewage Disposal System in accordance with
the provisions of TITLE 5 of the State Sanitary Code — The undersigned further agrees not to place the system in
operation until a Certificate of Compliance has been issu b the boa health. !�
Signe-------------- --- ---- .... ..�................................... -•-•-•---•-•.....-----------...-- l �f rCi��
Application Approved By. ------ -- ------ -•--........................................... -•-•---..../Date
Application Disapproved for the following reasojk- ---- --------•----------------------------------------•------•-----------------•-----------------------•-------
-------------------------------------------------------------------V------------------.......-----......--------------...----------------------------------------------- l-------
��
Permit No.----- ........................................... Issued ...... - -
Date
THE COMM-ONWEALTH OF MASSACHUSETTS" -"
�-� BOARDFHEALTH
O............OF.......... ..l CYC ............................................
Tnrtifirate of Toutp ianre
THIS IS TTC RTI,E.Y, T� the btu idual Sey%age Disposal System constructed ( ) or Repaired
ii�r-- rt�� v r ........................................................_J'
by -`�j..- ...----------•------------------------ .......................... -......................
�j O'- 1 � C r I ' " InstallR�•� )�Q
at............................................. --------- ---•------------ ............................I .. -----------------------------------------------------------------------------
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 NOT TRUED AS A GUARANTEE AT THE
SYSTEM WILL FUN ION ATISFACTORY.
DATE............... ........................... InsP...............