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HomeMy WebLinkAboutApp-Permit-Compliance©©3— Vb"3 Fss....�-..�............ No ......... Q.--•--------- THE COMMONWEALTH OF MASSACHUSETTS BOARD OF HEALTH -0L-t.� oF..........-.C�..Y.?'do1�l ... ............ Appliration for Dispnsttl Worko Cnnntrnrtinn ramit Application is hereby made for a Permit to Construct (. ) or Repair an Individual Sewage Disposal S stem at: souk &k :. A - ocation d' ss d _%r,- :j ...... _..--------.lug--------------------------- (0 'ss W�__ ._ - r.�r_ �y. ------------------------------------------------- Installer Address dType of Building Size Lot____________________________ Sq. feet U Dwelling —No. of Bedrooms............................................Expansion Attic ( ) Garbage Grinder ( ) aOther — Type of Building ____________________________ No. of persons ............................ Showers ( ) — Cafeteria ( ) a d W x Z a w U W U 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 IPerformed 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 ........................ - -- ---- -•l•----...•------------- / Description of Soil ........................ _.-.� ��®/---------.......................... --- -------- Description of ------- Nature of Repairs or Alterations — Answer when a licable___, - �" -------------------------------------------------------------•.-.----- �... o.i�. g ja)q---......................................................................... Agreement: The undersigned agrees to install the aforedescribed Individual Sewage Disposal System in accordance with the provisions of TIT112 5 of the State Sanitary Code — The undersigned further agrees not to place the system in operation until a Certificate of Compliance has beegn issued by the boavvof health._ if,r Application Approved By_.(��___� ........... D�.. .......3 Date Application Disapproved for the f olloiving reasons: ........... ------------------------------------------------------------------------------ =--__.___.__._.__---- --------- -Date•---------•--- PermitNo.�y........................................... Issued_---, - ----------------- Date „ ................ . THE COMMONWEALTH OF MASSACHUSETTS BOARD OF H�!EyA,+L`T�H OF... ...yar. f=-L.�':dt.................................. Trr#ifiratr of Toutpliatta THIS IS T? sc.i .'CY. RTIFY'That t: e„ . Ind-Av=.i- d al SeI`pwr atallgr r.�s pso.s1atl J System constructed or Repaired ......- --•-----• •------- ---------•----------- R” V/— r %( ir+ r.. .-. at ........................... 't ' -, ..._ .I_' -f. A---/--7 -_= W. �`��r c.!�c ri.�. .r �� �----•--•-------------•----•---...... has been installed in accordance with the provisions of TI �e tate Sanitary C� as re ibe m the application. for Disposal Works Construction Permit No____________________ ___________________ dated ..... _'_'...................... _................. THE ISSUANCE OF THIS CERTIFICATE SHALL NOT BE CONSTRUED AS A GUARANTEE THAT THE SYSTEM WILL FUNCTION SATISFACTORY. - Inspector.... -