HomeMy WebLinkAboutApp-Permit-ComplianceFRx...�_ —
THE COMMONWEALTH OF MASSACHUSETTS
BOARD F HEALTH
Appliration for Elispos tl Marks Cyr nstrurtion 1rrutit
Application is hereby made for a Permit to Construct ( ) or Repair (✓� an Individual Sewage Disposal
Systemat: ------------- - -----.............................................-
.......... ._---.._-------------1 .. ...---•------....••....
ca iw dd ss or Lot No.
ojV Add s
•.� ..... -- a - ......
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 ( )
Other fixtures
Design Flow............................................gallons per person per day. Total daily flow ............................................ gallons.
Septic Tank — Liquid ca.pacitv..�0.gQ.gallons Length ................ Width ................ 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. I...............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........................
Descriptionof Soil .......................................................................................................................................................
.... --- - ----
Nature of Repairs or Alterations —Answer when applicable...il6 ¢►C _ `�"'"...... __ _- ----
Agreement:
The undersigned agrees to install the aforedescribed Individual Sewage Disposal System in accordance with
the provisions of'I'1 , 5 of the State Sanitary Code — The undersigned further agrees not to place the system in
operation until a Certificate of Compliance has been issued by the board of health.
Signe �_!_! _ +.
� t
Application Approved By_
::�'------ ----- ----------------- .:=
Application Disapproved for the following reasons-----------------------------------------------------------------------------------------------------•••---......
.....................................................................�-...-----------------------------------------------•---------•-----------•----•----------......------...'.------------------------
Permit No..... .` = e_�.��U-------................... Issued._-.11 . ---
Date I-
--
THE COMMONWEALTH OF MASSACHUSETTS
/_- - BOARD OF HEALTH
........... .OF....: {��Y/�':17f:............................................
(Irrtifiratr of Toutpluturr
THIS IS TO CERTIFY,,lThat the Individual Sewage Disposal System constructed ( ) or Repaired
by..........9 -------------•--- ----'---------------------•---•-----.--.----------------•--------
................................
Installer
- -
has ,_.
been installed in accordance with th' e provisions of TITLE' 5 of The State Sanitary Cade as .described in the
application for Disposal Works Construction Permit No._.. � + j....... dated-,
PP 1.posa- F----------------------
THE ISSUANCE OF THIS CERTIFICATE SHALL NOT BE CONSTRUE® AS A GUARANTEE THAT THE
SYSTEM W� FUNCTION SATISFACTORY.
DATE. ��f'. f ''%�' ......_..... __ _
,r .. Inspector ._r...'. ._.. % :_.r_. -