HomeMy WebLinkAboutApp-Permit-ComplianceZ
C
L
L
THE COMMONWEALTH OF MASSACHUSETTS
BOARD FF HEALTH
0 ........... .OF ............ ... */? --- - - - - --------------------------------------------------
Appliratiou for Uhqpaoal Worko Tomitrurtion Vamit
Application is hereby made for a Permit to Construct or Repair an Individual Sewage Disposal
System at:
ry) o P - �se,
...... .........
.............. 24=.1
........ W Location or Lot No.
I& ......... ................................................................................
.... ...... ............. ......... . Address -------------- 7 ------- *
..........................................................
. ................ ........................................
......... . .. ........... .. ... Address
Type -`o`f--?,. ding Installer 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./00.qallons 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. f t.
Other Distribution box ( ) Dosing tank ( )
Percolation Test Results Performed by ----------------------------------------------------------- .............. Date ----------------------------------------
Test Pit No. I ................ rbinutes 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.._.._..__.........._.._
.............................................................................................................................................................
Description of Soil ----------------------------------
...............................................................................................................................................
Nature of Repairs or Alterations — Answer when applicable -------------------------------------------
........................................................................................................................................................................ ...... 1 ........................
Agreement:
The undersigned agrees. to install the aforedescribed Individual Sewage Disposal System in accordance with
the provisions of TIT; E 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..................... ............... ............................ ............ ............ D .. t . e .........
2- 9� __jj
Application Approved By ...................... 0.(.. ......... ... ............... ........... Da . t - e .. . .....
Application Disapproved for the following reasons: ---------
. I
Permit N
-------------- ..................
I Date
Issued ----------------
THE COMMONWEALTH OF MASSACHUSETTS
BOARD OF HEALTH
77-7a. ....... OF -A� . ........... I ...................................
. Trrfff;� mliftaurt
THIS IS TO CERTIFY,That the Individual Sewage Disposal System constructedk<) or Repaired
by.. .1 . ...... ............ . - - .......... . —. . .... .........................................................................
sc as ate Sanid i
5 of TC-I e
..e .
at ---- -------- - NICZa ---------------------
......................... -------------
The t d�F'
has been installed in accordance with the provisions of Tl;-�F,- 7 a4�e
application, for Disposal Works Construction Permit No/-A-:!.Tn'=2'4U�..... dated-- / ......... f... ..........
THE ISSUANCE OF THIS CERTIFICATE SHALL NOT BE CONSTRUED AS A GUARANTEE THAT THE
SYSTEM WILL FUNCTION SATISFACTORY.
DATE--------------------------------------------------------------------------------- Inspector