HomeMy WebLinkAboutApp-Permit-ComplianceNo...CQ ..4?=..........
THE COMMONWEALTH OF MASSACHUSETTS
BOARD F H LTH
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Applirtttiott for Dhgposal Works Tottstrurtiott Prrutit
Application is hereby made for a Permit to Construct ( ) or Repair (1-�an Individual Sewage Disposal
System at
40t 6112- SO
......... �S41A ....•• ocat: Address , . r Lot N
0
...
/.. ..1..........-.!rL... ....._�..-------------------------------•-- '�_�_.�-�-� 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 ( )
Otherfixtures------------------------------------•--.-..........-...-------------------•------------- .............................................................
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........................
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Descriptionof Soil ..------••--------------------•-••---.......--•-•-•---•-------..........-----•-•------------•---•-•--•----•---....--•-•---------------......---
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N of Re rsoj/Alteratipns —Answer when applicabl•.. .".........'.��le�.....
/ .sfp�rl r°111.......................................................................................................•..........:......................
Agreement:
The undersigned agrees to install the aforedescribeividual Sewage Disposal System in accordance with
the provisions of TITLE 5 of the State Sanitary Code -u ersi ed f rthe rees not to place the system in
operation until a Certificate of Compliance has been ' ue ea
Sig--- . --•--• .....--•-... .......... -................................... ...�r�
• at
Application Approved By------ •--•......................... ................... ............................
�
----•----•--- - ..........
ate
Application Disapproved for the following reasons ..................................................................................................................
...................•-------------------J--•-------••-----•---•••----•---•...--------•-----•-----.....-----------------•-----....--•--- ------....... --------•-
�Z
Permit No. .................................... Issued --- '--•---'- ( ?..
ate
THE COMMONWEALTH OF MASSACHUSETTS
BOARD 3DF HE/+..H
Gti........... OF..... ........... ................. .. .........................................
,� (Intifiratt of Tootphatta
THO_;. S' TO CE F,Y1,Vll rt tl ndividual Sewage Disposal System constructed ( ) or Repaired (�r
by........... .... `........ �✓rC� �'!� �/ ......•........... -- -- ------ '------------------------ - ..........._._......
nstall
at_ � .... CI � .._ 7 _........./L�. ... --------------------------------
has been installed in accordance with the provisions of T TLE 5 of The State Sanitary Code as described in the
application for Disposal Works Construction Permit No -------------------- 0.................... dated ..... ...........................................
THE ISSUANCE OF THIS CERTIFICATE SHALL NOT BE CONSTRUED AS A GUARANTEE THAT THE
SYSTEM WILL FUNCTION SATISFACTORY.
DATE......... ..- `� -P` s�----•---•-----•---------------------- Inspector---- . •. C -�