HomeMy WebLinkAboutApp-Permit-ComplianceNo...":/ Fes$ �.......
THE COMMONWEALTH OF MASSACHUSETTS
1 BOARD OF HEALTH
........... OF ..... .....j.. ....... --------------_-..._..... .........................
for Uivjiooa1 Works Tootitrr' ernti
Application is hereby made for a Permit to Construct ( ) or Repair ( an Individual Sewage Disposal
System at
.............� ...------.�___�...-- . ........... .............
ocation - Address No.
-....................................•.....................•---....... � ..- .-- ..
or Lot
Owner A ress
a �%..e4 -. ........................ — ... . -- .... -- . ........
Address ...-.. ..
Installer
Type of Building Size Lot ---------------------------- Sq. feet
V Dwelling —No. of Bedroo ___--,............... .....................Expansion Attic ( ) Garbage Grinder ( )
pa, Other — Type of Buildin ............................ No. of persons.___.___________--_______. Showers ( ) — Cafeteria ( )
�+ Other fixtures
W Design Flow-•.------.•_•--_____.--•-•• -_--•-- ------ s per person per day. Total dailyflow ___-----•----------------------------------- gallons.
WSeptic Tank —Liquid capa ity.... ....__ga s Length ................ Width ................ Diameter ................ Depth ................
x Disposal Trench — No ................. Width........ _......... Total Length ................ _--- Total leaching area .................... sq. ft.
Seepage Pit No___________ _________ Dia ter......__•______...-_ epth below inlet .................... Total leaching area .................. sq. ft.
Z Other Distribution box ( ) Dosing tank )
PercolationTest Results e ormed by ------------------- ..................................................... Date ........................................
aTest Pit No. 1 ______________;_minutes per inch Depth o Test Pit .................... Depth to ground water ........................
Test Pit No. 2................minutes per inch Depth of Test Pit .................... Depth to ground water ........................
R'+.-----------•-----------------------•-----------•-----•---------...-•---.........----------------••..........................................................
0 Description of Soil ........................................................................................................................................................................
x••••----•••------•••---•---•-••-•---•---------------•-----••---------•••-••----•--------•-•...--••••.........•---••.......•--•---•--•••-••-••-•••-•---...-•••-----•-•...-------------•-••-•---•----•••.
V
•---------•--------------------------•------ ------•--•-------------•----•----------------------..............
Nature of Repai Al er ions — Answer when applicable_ ----_--- __ _.... I ••..
_.. ���
Agreement:
The undersigned agrees to install the aforedescribed Individual Sewage Disposal System in accordance with
the provisions of iITL L 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.
Signed...................................................................................... ................................
�)� ��j' -•--•------------- Date
Application Approved BY-----. --...
s, Date
Application Disapproved for t )101t%i'If PCORS: --------------------------------------- -----------------------------------------------------------------------
-----------------------------------
Date
PermitNo ......................................................... Issued .......................................................
Date
THE COMMONWEALTH OF MASSACHUSETTS
BOARD OF HEALTH
(Intiiirab of foot �i �tr�e
THIS IS TO CERTIFY, TVat�fhe In4ividual Sew�:age D' I System constructed ( ) or Repaired (
by -------------------------------------------
Installer:= x '� ......
t r "
..
at i..-------- ----""
has been installed in accordance with the provisions of TIT. ,Z- 5 9 T,.h-pe- S• to Sanitary ode as �les+rila�d xt the
application for Disposal Works Construction Permit l� o e' `__ as C dated_ :. ,f
THE ISSUANCE OF THIS CERTIFICATE SHALL NOT BE CO TRUED AS A GUARANTEE THAT THE
SYSTEM WILL FUNCTION SATISFACTORY.
DATE............................•-•----••--•----•---.....---....------••------------ Inspector ------------------------------------------------------------------------------------