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Home My WebLink AboutApp-Permit-ComplianceM U F�- THE COMMONWEALTH OF MASSACHUSETTS BOARD OF HEALTH Appliration for Disposal Varks Tatra wftu Permit Application is hereby made for a Permit to Construct (K) or Repair ( ) an Individual Sewage Disposal Systemat: M ... ..... ..... .......... ..».»............................ _ •tion - Add s or No Lot A..C/.-/----............. .._.... ..... .. ...........-....�� Addres...l..Y_? ....».... ... Installer Address Type of Building Size Lot_ l®&. L15.......Sq. feet Dwelling —No. of Bedrooms..............3 ....................... Expansion Attic ( ) Garbage Grinder ( ) Other — Type of Building ... ______------- _.... _------ No. of persons ............................ Showers ( ) — Cafeteria ( ) Other------------------------------------------------------.......------=---------..........-----............... ..... Design Flow ....... _____________________gallons per person t +day. Total daily, flow ......._........3J©........... tlo�ns. Septic Tank =Liquid'capacity.(COQI� allons Length...--... Width ................ Diameter ................ Depth...:L Disposal Trench — No ..................... Width .................... Total Length .................... Total leaching area ....... _....... -_.sq. ft. Seepage Pit No..... ... Diameter ..... lC2 Depth below inlet .... �.��..�.... Total leaching area... ��R. _..-.sq. ft. Other Distribution box ( ) Dosing tjw,* ( ) a9 z Percolation Test Results Performed .. .�. _;�� 1 Date._ .:......-»----... c...)........... Test Pit No. I................minutes per inch Depth of Test Pit_... ..4..... Depth to ground water .... Test Pit No. 2................minutes per inch Depth of Test Pit ................... Depth to ground water ........................ Soil.... .��' ��-.`._. i...................... � Description of .�:....�!'.Y��(�C.1�1.:1.`.........�.....�....-» .. ..............................................................................................».....---------------......._........................_.............................-•---......»».._-- Nature of Repairs or Alterations -A�isw r when applicable............................................................................. Agreement:5 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 hasrb t e board of health.S- ed... ......................».._....----............Application Approved By.. ... .. �__........ .. ............................_ _....ld /..3 ...:3..._.... Date Application Disapproved for the follouring r on__•_-__....___•____._......_•________•____......___•__•___......._................._........_.... ..................................................•-LC-�------.._......_........._........_.........-----.---...........------------------...........................- .. �---......................___ Daft Permit No .... 1 .........// _l:_..--------•----..».._ Iwued.---1-!!��..3/... -:: ..... Date THE COMMONWEALTH OF MASSACHUSETTS BOARD OF HEALTH &rtifirate of faoutpltmt THIS IS TO CERTIFY, That the Individual Sewage Disposal System constructed ()() or Repaired ( ) b---• --�•J- �_ C ....... G si:^!.f.�......: . f�-...................... -................ »_..... —---------- _------- »------------ ----- ____»» j(.-_---...o.,®.. 2 ..1 r+ 6 , �Tl�/ Installer ! . .- .. has been installed in accordance with the provisions of TITIE 5 of The State Sanitary Cod as d scribed in the application for Disposal Works Construction Permit No.._ .. _'..._ `� yl/..................... dated.... ..%?.........------.. THE ISSUANCE OF THIS CERTIFICATE SHALL NOT BE CONSTRUED AS A GUARANTEE THAT THE SYSTEM WILL FUNCTION SATISFACTORY. DATE............................................................... ......... - .... -- Inspector ....................... ............................ ..... ....... .-...............