HomeMy WebLinkAboutApp-Permit-ComplianceE0
NoFps ..............................
No' -11
.�,�.....
THE COMMONWEALTH OF MASSACHUSETTS
BOARD OF HEALTH
OF.......................................--------------------------------------------------
for
-----...------......------__..._..------------._.flar Ropoal Works Toustrudion Vamit
Application is hereby made for a Permit to Construct ( or Repair ( ) an Individual Sewage Disposal
System at:
............... ..........
Locat' n •Address
Lo
...... - .......... . r ...
- Add
/ caner ................................../'�t
Address
Installer Address .
Type of Building Size Lot._06<2..... Sq. feet
Dwelling — No. of Bedrooms.....................................Expansion Attic ( ) Garbage Grinder ( )
Other — Type of Building ............................ No. of persons -•_-----________ -_._.._-_•• Showers ( ) — Cafeteria ( )
Otherfixtures ----------------------------------- ----------------------------------------------
9"0",
Design Flow....._.« ......................... gallons per�Plr"
day. Total daily flow.._•-..•___. -------------- gallons.
Septic Tank —Liquid capacity/0.0!2-gallons Length__ ---_-. Width..... .... Diameter ................ Depth!.___._...
Disposal Trench — No. _ -_._--__---•_-- Width ................... Total Length .................... Total leaching area ............ ... sq. ft.
Seepage Pit No ....../ D'ameter.../o-..S _. Depth below inlet....��rs ..`_--- Total leaching area:�� sq. ft.
Other Distribution box ( Dosing tank ( )
Percolation Test Results Performed by.��? `r-----r�-'------ Date_:1`��--------
Test Pit No. 1................trlinutes 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 -------- -7'3; �_....-f ------16:74.142
---•---•-••---------------•--•-•----•-----•--•--•.----•••----•----.....-----...-•-------...-------•-...-------•-•--•--------•--•--------•••-----•--•-•---•-.•-•-------......
--------------------------------------------------------------------------------------------------------------------------------------------•--- ...
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 T IT IIE 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.
Sig ed c o� ,� .. ....
......
-
D e
Application Approved BY----•-......----••----• •••--- z
D ate
Application Disapproved for the following reasons: ...........................................................
by
Permit N
Date
Issued--------------------------------------------------------
Date
THE COMMONWEALTH OF MASSACHUSETTS
BOARD OF HEALTH
.......................................... OF .....................................................................................
Tntifiratr of T autpliatta
THIS IS TO CERTIFY, That the Individual Sewage Disposal System constructed ( ) or Repaired ( )
Installer
at------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------
has been installed in accordance with the provisions of TITLE r ofT e State Sanitary Code as describe in the
application for Disposal Works Construction Permit No..__._f__-n,1----- dated___.._____.+!C1�..2___ ._�.
THE ISSUANCE OF THIS CERTIFICATE SHALLNOT BE CONSTRUE® AS A G9JAECANTEE HAT THE
SYSTEM WILL FUNCTION SATISFACTORY.
DATE......................... { Inspector ............... .....................................................................