HomeMy WebLinkAboutApp-Permit-ComplianceNo ... FnB ............... ..............
I.a.— .15.1-
THE COMMONWEALTH OF MASSACHUSETTS
BOARD OF HEALTH
.............. ...... .........................................
Appliration for Disposal Works Tonstria#njhmmit
Application is hereby made for a Permit to Construe
l
System at:
................ . .... ..... ;'. 'O.�.
... Address ... . . ...................................
........ ....
Owner
Installer.........
or Repair
Type of Building
Dwelling —No. of Bedrooms -------------------------------------------- Expansion Attic
Other — Type of Building ............................ No. of persons.......................
n+11 'q+
Address
Size Lot ............................ Sq. feet
Garbage Grinder
Showers ( ) — Cafeteria
er......................................................................................................... -
Design Flow -------------------------------------------- gallons per person per day. Total daily flow ............................................ gallons.
Septic Tank —Liquid capacity ............ 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 ..... /0-O.Cp .... .............
...................... ----------------------------------------------------------------------------------------------------------------------
Agreement:
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 has been issued by the board of health.
Signed...................................................................................... ................................
Application Approved By------- 46-L.. ------------- ----------------- .................... Date
- Date e ..............
p Qjth-officer
Application Disapproved for t,beowing reasons: ................................................................................................................
.................................................................................................................................................................... ....................................
Date
Permit` No --------------------------------------------------------- IssuedL .......................................................
Date
I
THE COMMONWEALTH OF MASSACHUSETTS
BOARD OF HEALTH
............ .......... OF ....... ...................................
Trrtifira lalf (9jantpliattrr
THIS IS.. -TO CERTIFY Th t the Individual Sewage Disposal System constructed or Repaired
by.............. ............... 7 ------- -------------------------------------------------------------------------------------------------
er
...................................................................
at ------------- .... - - ------- .............................................
has been i/__,,_.�ed in ..,dance with the provisions of TITLE off The State Sanitary Code as described in the
.-I C�_
application for Disposal Works Construction Permit No../_O=i� ........ ......... dated ................................................
THE ISSUANCE OF THIS CERTIFICATE SHALL NOT BE CONSTRUED AS A GUARANTEE THAT THE
SYSTEM WILL FUNCTION SATISFACTORY.
DATE............................................................................... Inspector