HomeMy WebLinkAboutApp-Permit-Compliance,..
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THE COMMONWEALTH OF MASSACHUSETTS
BOARD OF HEALTH
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Appliratiou for Dispniial Works TonStrnrtinn Frrmit
Application is hereby made for a Permit to Construct) or Repair ( ) an Individual Sewage Disposal
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L Address
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Owner y�-(p
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� •- � Installer t�
ddress
Type of Building Size Lot ... �..�4_4:)�a---- Sq. feet
V Dwelling — No. of Bedrooms -------------- Z... ...................... Expansion Attic ( ) Garbage Grinder (VO)
Other —Type of Building ____________________________ No. of persons- _._•-_•--•_•..__-__----- Showers (/) — Cafeteria ( )
dOther fixtures ...... Z-)2-------- --•-•-•-----•-----------"---.----"••-----------•"------•------------------•------•------"--.........---......_._...__....._.
Design Flow --------- per person der day. Total dail �ow___._.._---"?.C�....------•-_---- lon sa
W hAy _ ..- Diameter__ _ .. _ __ De
WSeptic Tank — Liquld ca aclty�l�.:. allons Length_ -.-Icy..._ Widt __. • -- - - -- P �••
Z Disposal Trench — No�1.. ��.. i I th.._.._Si a.___..._ Total Length..._ .._._ Total leaching area.........:..........sq. ft.
Seepage Pit No ..... ................ Diameter .................... Depth below inlet .................... Total leaching area .................. sq. ft.
Z Other Distribution box ( ) Dosing tank ( )
1-4s Test Results Performed bY-•----------•---•---•....-•---•-•-"•-••--------•--•----•. Date `� i
a Test Pit No. 1 ........... per inch Depth of Test Pit..... �..Z..•.._. Depth to ground water .....
(14 Test Pit No. 2................minutes per inch Depth of Test Pit .................... Depth to ground water ........................
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O Description of Soil.---------- ...........! t i..l�.'
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W----•----••----------•-----•-------•-----------------•-------------------•-"---------------•----------"•------------" -•------"•-----------"-------"---------"-------"------•--"....._...------
VNature of Repairs or Alterations — Answer when applicable............................_._._....._.._._.....__..........._.._..•._...•.._....____..........
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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 is ued by the oard of health.
Signed-- - � ---• - - ------
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Date
Application Approved BY _-..................."--...__..... � y-``523
Date
Application Disapproved for the following reasons: --_--------- -----"••---•-•"----"--------------------------"-------------"•-••----"-----"-••------•--•--•----
Date
Permit No..-•_��.___-------------- Issued ... _ = .,lam-- ^..................
Date
THE COMMONWEALTH OF MASSACHUSETTS
BOARD OF HEALTH
Trrtifiratr of Toutpliatta
61' THIS IS, TO CgRTIFY, That t IInividual Sewage Disposal System constructed or Repaired ( )
Installer
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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 NocR?_:-_ �" -5_1-C' ................ �-? ..............
THE ISSUANCE OF THIS CERTIFICATE SHALL NOT BE CONSTRUE® AS A GUARANTEE THAT THE
SYSTEM WILL FUNCTION SATISFACTORY.
DATE..... _ - ..2' 2 ............................................ Inspector-- `------------------•--.
