HomeMy WebLinkAboutApp-Permit-ComplianceFss.... _..... ......
THE COMMONWEALTH OF MASSACHUSETTS
BOARDr%F HEALTH
�U..I.TI-
.._.... r�1� .........:OF.---. ...-------------------------
Appl ration for Disposal Works Ton,strnrtiun jhrmit
Application is hereby made for a Permit to Construct ( ) or Repair kan Individual Sewage Disposal
System at
�P.._ ..t . �....... ... .._P., .......... ......................... -- MTRLocation - Address or Lo
�;_�_
�= C . .............................................. ..........•-----...----..------...... .. ------------------.....-----------....----
-F-22-5
-- -------------- -Owner Address
= . .Ld--•-•••---•---•-----•-•---•••-----•--------------- --------•-•------•----...•------•--------------•----•-----------•-----...................---...---
Installer Address
Type of Building Size Lot ............................ Sq. feet
Dwelling —No. of Bedrooms ............ ..........................Expansion Attic ( ) Garbage Grinder
04 ad Other — TYPe of Building ............................ No. of persons ............................ Showers
Cafeteria
Other ( )
fixtures-------•-------------------------•------------....---.-----•-•-------•------••----•-•-
W Design Flow............................................gallons per person per day. Total daily flow ............................................ gallons.
WSeptic Tank — Liquid capacity ............ gallons Length ................ Width ........ ........ Diameter ................ Depth ................
x Disposal Trench — No ..................... Width .................... 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 ( )
Percolation Test Results Performed by ......................................... ................................ Date ........................................
Test Pit No. 1.............•..minutes per inch Depth of Test Pit .................... Depth to ground water ........................
fs, Test Pit No. 2................minutes per inch Depth of Test Pit .................... Depth to ground water ........................
0' ...................... --....................... -.................................................... .........................................................
Descriptionof Soil ........................................................................................................................................................................
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W
G Nature of Repairs or Alterations — Answer when applicable.,/ --5— �._G: S:f _-_. x ..........................
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Agreement:
The undersigned agrees to install the aforedesc • d Individual Sewage Disposal System in accordance with
the provisions of'ITL : 5 of the State Sanitary C e The undersigned further agrees not to place the system in
operation until a Certificate of Compliance has bee ssuTe�
the b, of health.
t--•-----.--•--- •------••-••f------------- ----- ------ -----•---•---•-----
Application ApprovedBy--•------• _---.... --------------------•----.. --- e
Date
Application Disapproved for the following reasons- ---------------------------•--------------------•-------------...-------------------------•-•-•--....--•----•---
--------------•---•-.........._................-•-•---•---•-•---••-•-------•-.........-----......-•--•-•-•-------•-•••--------------._......... --- •-----• ------:•••------•-••••--.........._-•----
Permit No. _ _ /,yz..-•----...---•---•-------• Issued ... �� .-�-•.............. nate .-----
Date
THE COMMONWEALTH OF MASSACHUSETTS
BOARD OF HEALTH
........................OF.........................................
Tnrtifira � of Tontrrliaurr
- THIS IS TO CE�R?TIFY, That the Individual Sewage Disposal System constructed ( ) or Repaired
by--.....7� ........----------------------------- --............. -.............................................................................
,,�stdll r
at . t ...... - '..._..
has been installed in accordance with the provisions of TITLE 5 of The State Sanitary Co a as sc ibed in the
application for Disposal Works Construction Permit No.___. __,—_ ,� `��� dated__.._.. ...._Z ....................
THE ISSUANCE OF THIS CERTIFICATE SHALL NOT BE CONSTRUED AS A GUAR NTEE THAT THE
SYSTEM WILL FUNCTION SATISFACTORY.
DATE................................................................................ Inspector