HomeMy WebLinkAboutApp-Permit-ComplianceN05g-..IOC) .--- FEB t
THE COMMONWEALTH OF MASSACHUSETTS
BOARD OF HEALTH
tOF ....... ... .......... .------------------------------------------.
Appliration for Di-qV.a,ial Marks Tomitrnrtiun 11amit
Application is hereby made for a Permit to Construct
System at
...... /4 -.,. cation - A - ressr
Ow er
- --------------
Installer
Type of Building
Dwelling — No. of Bedrooms......
Other — Type of Building .........
+1'' fixtures
( ) or Repair ( �an Individual Sewage Disposal
..........................Expansion Attic ( )
Lo
or t No.
Address
Address
Size Lot ............................Sq. feet
Garbage Grinder ( )
....... No. of persons ............................ Showers ( ) — Cafeteria ( )
e------------------- ---------------- --------- ........................................ ---------.__..-----------------------------------------------
Design Flow............................................gallons per person per day. Total daily flow ............................................ gallons.
Septic Tank — Liquid capacity ....... ..... gallons Length ................ Width ................ Diameter ................ Depth ................
Disposal Trench — NTo..................... 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 .........................
Description of
----------------------------------------------------------- A.fJt/[�-u`
Nature of Repairs or Alteratio —Answer when applic le._ __ _ _ � _______.! _..___.._. r
----------------------------- / ------ . �- ..---.
Agreement:
The undersigned agrees to install the aforedescribed Individual Sewage Disposal System in accordance with
the provisions of 'TTL, of the State Sanitary Code — The undersigned further agrees not to place the system in
operation until a Certificate of Compliance has besp issued by the b9ard 9f health.
Application Approved By
Application Disapproved for
Permit No. o�_-./00
Date
---------------------- ----`------------------------------
Isstl_---- Date ......
THE COMMONWEALTH OF MASSACHUSETTS
BOARD OF HEALTH
t$ .....
............*--:"......... OF.... !i. I ! .......:.....................................
C�irxii�irtt ui f1��am�li�tnrr
THIS I TO CERTIFY, That the Individual Sewage Disposal System constructed ( ) or Repaired (� )
byL �� n �t.cA c ... 1 - ----- --------•-----------------------•---------------------•--•------------------------------.........---
nstailer
at1.-%-ft'u &-------------------------------------------------------------------------------
has been installed in accordance with the provisions of E r" f The State Sanitar od - in the
application for Disposal Works Construction Permit �'o �- tiJ°�____.....•._.....__ date_._..._ _�-y-,-��-----•_------
THE ISSUANCE OF THIS CERTIFICATE SHALL NOT BE CONSTRUED A ANTEE THAT YHE
SYSTEM WILL FUNCTION SATISFACTORY.
DAT��/_...................................... Inspect -------------------------------- --