HomeMy WebLinkAboutApp-Permit-ComplianceNol� .. ...._ .1�`.� FEB
THE COMMONWEALTH OF MASSACHUSETTS
BOARD 2F HEALTH
OLC%O F .... ...-------------------------------- ---------
Appliratio i for Disp.Qii al Warks TomitruranIndividual
fermi#
Application is hereby made for a Permit to Construct ( ) or Repair ( Sewage Disposal
Y aewr.
S stem at............ --.../zc.!,p
.l ........... /`� ._.....QQ--- -
0
,j f Location - Address or Lot No.
-`�----------•---•••----------------------------•----------------------------------••- ------•------------------•----------...._.----
wner Address
dltJ,S/�
------------------------------------.--•----
Installer 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 ........................
----•----•-•-----------------------------------------------•----......----------_.___..-----•----•-. ---•--------•-••--•....------••-••-•--••----...----------
Descriptionof Soil ........................................................................................................................................................................
-------------------------------------------------------------------------------------- ------------------------------------- j ----------.....--•--------
Nature of Repairs or Alterations — Answer when applicable-•--•�------{xSdS
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Agreement:
The undersigned agrees to install the aforedescribed Individual Sewage Disposal System in accordance with
the provisions of TIT1L 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------------------------------•-------------.._.........------------------....--------.......................
Date
Application Approved By ............
--------- . ........� . --•-----------------------•------- ----.........-------------------
Date
Application Disapproved for the following reasons: -------•------•-------------•---------------------------------------------------------------------------
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Date
PermitNo ......................................................... Issued .......................................................
Date
THE COMMONWEALTH OF MASSACHUSETTS
BOARD OF HEALTH
.............. OF ........ ..fc?!.4..cr.!�� ...............................
(9rdifira of Toutpffiturr
THIS I TO CERTIFYIrhat the Individual Sewage Disposal System constructed ( ) or Repaired (I�
In,�taller
atercor;nce------------------
has been installed in a with the provisions of TITLE 5 ofYhe State Sanitary Cod a des ibe In the
application -for Disposal Works Construction Permit No.. -146......... dated _--.___---../... .......�...........
THE ISSUANCE OF THIS CERTIFICATE SHAL NOT BE CONSTRUE® AS A GU RAN EE THAT THE
SYSTEM WILL FUNCTION SATISFACTORY.
DATE................................................................................ Inspector