HomeMy WebLinkAboutApp-Permit-Compliance.r
12
0
THE COMMONWEALTH OF MASSACHUSETTS
Fic$......��
�� BOARD Yfi)?
OF HEALTH
..ra..... ..................... OF... ........................................................
Appliration for Disposal Works Tonsirnr#inn jrrmit
Application is hereby made for a Permit to Construct ( ) or Repair (/ an Individual Sewage Disposal
System at:
-.-„-- Location - Address -. or Lot No.
--....... j...Qv! ,5. M ................................. .......--•-------------•--•--......•--.............--••--....-------•----..................
Owner Address
............ ........ ......................... -----•-----•------------------•--•-•----•...... ....... - ..................
Installer Address
Type of Building Size Lot ............................Sq. feet
Dwelling —No. of Bedrooms.....................................Expansion Attic ( ) Garbage Grinder ( )
Other — Type of Building ............................ No. of persons............................ Showers ( ) — Cafeteria ( )
Otherfixtures .----------•...............................................---.....----•----........-----.....---------......---------------..._......------------•---
Design Flow............................................gallons per person per day. Total daily flow ............................................ gallons.
Septic Tank — Liquid' capacity/.4.0o .gallons Length_8 ` 1°.:''_'. _ Width..'? .2!! ""Diameter .. Depth...
Disposal Trench — No ..................... 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 Dep^ of Jest Pit.................... Depth toy ground water........................
------- ---
Description of Soil ..---_ 1!5'
------------ s'---------------------------------------------
........--•------•------------------------------•---•---------•----•-•---•-•----•-•-•-------------------.......--------------------•-----------------------•---•-•--------------......
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 TITIS 5 of the State Sanitary Code — The undersigned further agrees not to place the system in
operation until a Certificate of Compliance ha een ' sued by the board of health.
ne m - -..` =G------------•--•------...lCl cByg
Application Approved By ......... s-- . --- .. ---•---•------------------•--•-•.-_..._ Dap % .
'} Date
Application Disapproved for the following reasons----------------•-----•------------------------------•--•--------------------•--•-•------ ...................
PermitNo..-----..-- . D.......................................
...............•---..................
I.1981z
N��flSS" fjGI1L Cf%/QE) THE COMMONWEALTH OF MASSACHUSETTS
BOA79 OF HEALTH 1'
Jd ...................................., OF.. .JPW u7Vl.........................
.........................-...
�rrti�utt,aaf f��ant�rii�tnrr
THIS aS TO CERTIFY, That the In�Mgual Sewage Disposal System constructed ( ) or Repaired (�)
by -- tiT,,4cTOQ -- ... ._._.... ..........-
jt�j-, ..........�.j
`lln�ER�m� ISO►- : Sc�14 H yFlR 111)
has been installed in accordane with the provisions of T T F of The State Sanita Code as
application for Disposal Woks Construction Permit No. �.- � ______________________ dated _ ......._._...
THE ISSUAN E-)OF THIS CERTIFICATE SHALL NOT BE CONSTRUED AR
SYST LvFNCTION SATISFACTORY.
.
DATE. Pc%l6S - --. Inspector. -• .......................... �-
...... �..................... -
..........
a the
THAT THE