HomeMy WebLinkAboutApp-Permit-ComplianceFE304 :....T..-.
THE COMMONWEALTH OF MASSACHUSETTS
BOARD OF HEALTH
......... ..................... O F......_...................._..........---------------------..............._...........----
Applira#ion for Disposal '.Forks Cnonstrurtintt rerutit
Application is hereby mad r a Permit to Construct ( ) or Repair (j an Individual Sewage Disposal
System at: __%I1..:�or
......................... -- -----•---...........------...............ocation - Address Lot No.
... .. .•
Address
----------------••---......-----'-- ...
nstaller 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 ........................
------•----•----------------------•-------••-------•-------•-•-•-••---•-•...0....------••------•-•-. .........................................................
Descriptionof Soil ...................................................................................................................................... .................................
-----------•-------•---------------------•-•---'--------•----------•-•-----------• •----.....-------•---------------------••--
--•--•------ - ---------- --- ------------------• . ---•-•------•--- = - ...
Nature of Repairs or Alterations — Answer when applicable'.._____s
-------------�..----------
Agreement:
The undersigned agrees to install the aforedescribed Individual Sewage Disposal System in accordance with
the provisions of TITL J 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.
D to
Application Approved By.....Areasons
.--•----•-----------------------------•-----• a cJl�
Date
Application Disapproved for the f ollowin----------------•------------------------------••------•-------------•-----------
---------------------------•-----•-------•--••--------------------------------------------------------------•-------------------------------------------------------------- ----------•-----------
Date
-(� 7
yIssued----------- Permit No.--••-----••-•....-----•------ -.. a
l .
THE COMMONWEALTH OF MASSACHUSETTS
BOARD OF HEALTH
.......................................... OF .....................................................................................
ntilirair of Tl mptiattrr
THIS IS TO C Y T the Individual Sewage Disposal System constructed ( ) or Repairedby U�
.--------- ----•----------------0-�
------
��d �/at----......---------------•--• --r--�'-' --'• ---_ .L1.--------'-�'"�"'""-- - _.
-------^' ...................................................
has been installed in accordance wit'n the provisions of TI F 5 of T eI ate Sanitary Code s de -c 'bed in the
application for Disposal Works Construction Permit No ................ dated__ ------ -- �-------
THE ISSUANCE OF THIS CERTIFICATE SHALL NOT BE ONSTRUED AS A G ARAN EE THAT THE
SYSTEM WILL FUNCTION SATISFACTORY.
\
DATE................................................................................ Inspector