HomeMy WebLinkAboutApp-Permit-Compliance1�14PNo._
THE COMMONWEALTH OF MASSACHUSETTS
F$s...... p"w
BOARD OF HEALTH
. .......... OF..... . a,.W ....................................._----------
Applutttiun for Disposal Varks Tonut-ttrtiun Frrntit
Application is hereby made for a Permit to Construct
System -at:
Location -Address U
.. � - -------•--- (R-.0._....... .. --•-•-----
- ...... i.9�.. " c_ ....................
Installer
) or Repair ( Individual Sewage Disposal
-------------------------�.......: -! o. ...--------- . 6:�2! Nl too
or Lot No. ) � / /O
Inr.�......................., 9 _ . !' .............................. I
P.
Address ....................
..........
Address
Type of Building Size Lot ............................ Sq. feet
Dwelling —No. of Bedrooms -_ .3 ...................................Expansion Attic ( ) Garbage Grinder ( )
Other — Type of Building ............................ No. of persons ............................ Showers ( ) — Cafeteria ( )
Otherfixtures.......................................................------•----•---------------------...............-----.................................
Design Flow ......... 2 - ....................gallons per person per day. Total dail flow ...... ........._..._...._gallons.
Septic Tank —Liquid* capacity. gallons Length .... F_.... Width..-s�-.------: Diameter ................ Depth ................
Disposal Trench — No- -------------------- Width .................... Total Length .................... Total leaching area ................... sq. ft.
Seepage Pit No ...... J� ............ Diameter._..._J..� 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.................................•-----------...................---------------•-----------------...----•
--
Nature of Repairs o Alterations — Answer when applicable........ !-L���._ L._...
- ----.. 5�: �:..%....... !�---....---0 -6.6 -----y ..... � ` � ------ ---�9 r
Agreement:
The undersigned agrees to install the aforedescribed Individual Sewage Disposal System in accordance with
the provisions of TITI.i 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 ,1e boaa.Qf health
Application Approved
Application Disapproved for the following reasons:....
Date
Date
........................................•-••--------.._._._...................................... ----------- -----------------------------------
- � ------
Permit No ........
.. kle
_ -- ......_� Issu ...- D - .........r,,.,r.��..-
ate
THE COMMONWEALTH OF MASSACHUSETTS
BOARD OF HEALTH
0. .......OF.... ........................................
(grr#ifiratr of Toutpliunrr
THIS IS TO CERTIFY, That the Individual Sewage Disposal System, constructed ( ) or Repaired
by....................... ....... J..�.. !�! .. c�P' ` L— a - ..... ..............
i I s aver
at................................... ......... ......... ,- "'°-Y_S ..... ......-----------------._...............-....._...............
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 dated __-.____.1�
THE ISSUANCE OF THIS CERTIFICATE SHALL NOT BE CONSTRUED AS A GUARANTEE THAT THE
SYSTEMIL�LFU CTION SATISFACTORY. a
DATE. .s? .......... Inspector.:/3h ..... .................................................... .,,�._ ..
.. � .... .