HomeMy WebLinkAboutApp-Permit-Compliance-" ..Ire
-
Fms..........�� ........
Application is hereby made for a Per it to Construc-
S stern at
rLocation - AdVess
Owner
W
14
Qi
U
a
a
Wd
W
z
a
a
w
P4
O
U
w
x
U
THE COMMONWEALTH OF MASSACHUSETTS
BOARD OF HEALTH
�0.-l.�r�✓..................oF. ......���1,1T�/`...
Appliration for Disposal Works Tontrndion rnmit
t ( or Repair ( ) an Individual Sewage Disposal
�f M� rr)a
- - - - -- or. Lot No. •• --------•---------------
...-•--•--•----.
Address
-----------------------------------------•-•----•-----------------------•----------------•••-------•----------•-----------------...--------•---•---............................. ---................
Installer Address
Type of Building Size Lot. feet
feet
Dwelling — No. of Bedrooms ........ ............._------------_--_-Expansion Attic ( ) Garbage Grinder
Other —Type of Building ............................ No. of persons ............................ Showers ( ) — Cafeteria ( )
Otherfixtures------------------------------------------------------•-•--------•-••------•-------------------•. . ......................................
Design Design Flow........... 7�25�..................gallons per person per dV. Total daily fl....-.................gallons_
Septic Tank — Liquid' capacity-4457.gallons Length_. �.'..� _.,f ----- Width_. 5._ Diameter ................ Depth_..1�..�%=�
Disposal Trench — No ..................... Width ....... /-------- -. Total Length ............... / .. Total leaching area .................... sq. ft.
Seepage Pit No .......... /._....... Diameter ...... A........ Depth below inlet ---...l:........... Total leaching area ------------..... sq. ft.
Other Distribution box ( ) Dosing tank ( ) e
Percolation Test Results ,Performed ............................�r.............-... Date.....f� �_ 4 ............
Test Pit No. L.25el-Z..minutes per inch Depth of Test Pit..//Depth to ground water---------------------- -
Test Pit No. 2.... f�.-��minutes Der inch Depth of Test Pit__/5l®_____ Depth to iyrn,mrl wntPr
Description of
Nature of Repairs or Alterations
---------•-- ------
- Answer when applicable.-------------------------------------------------------------------------------------••---•---
------ -......................................................................................................................................
Agreement :
The undersigned agrees to install the aforedescribed Individual Sewage Disposal System in accordance with
the provisions of TITLE 5 of the State Sanitary Co The undersigned further agrees not to place the system in
operation until a Certificate of Compliance has be " i ed by tTq board health
.----.......- /------... .. ......--•----•--
Application Approved B �1 _. • J! 0-...............
Date
Application Disapproved for the following
-------------•-------.....----------•--•------.....------....-•----------------........---••--------------------....---------•••---•............................................
Date
Permit No .... ._..�------------------ Issu p�
THE COMMONWEALTH OF MASSACHUSETTS
BOARD OF HEALTH
..................OF............................................
(irdifiratr of Tompliattrr
THIS IS TO CERTIFY, That the Individual Sewage Disposal System constructed or Repaired ( )
by...................•••-•---•-------............---•--•----.........
. Installer
has been installed in accordance with the provisions of TITLE�yyof The State Sanitaryoas described in the
application for Disposal Works Construction Permit No. 't_=:: ....._..._.. dated .. `___________________________
THE ISSUANCE OF THIS CERTIFICATE SHALL NOT BE CONSTRUE® AS A UARANTEE THAT THE
SYSTEM WILL FUNCTION SATISFACTORY.
DATE._ 6,21.gL---------------•. Inspector �-= % �.. ... --- • ---