HomeMy WebLinkAboutApp-Permit-ComplianceTHE COMMONWEALTH OF MASSACHUSETTS
BOARD OF HEALTH
........... T�.�Q............ --OF........`i�9.•�..��.�_►1.t.�
, ppliration for Disposal Works Tonstrurtinn runtit
Application is hereby made for a Permit to Construct
System at:
Location - Address
Owner
----------------------
Installer
Type of Building
( ) or Repair ( vl� an Individual Sewage Disposal
LOT- V
or Lot No.
Dwelling —No. of Bedrooms ................ %__-___..__________________Expansion Attic
Other —Type of Building ____________________________ No. of persons ...................
Other fixtures
Address
Address
Size Lot ............................ Sq. feet
Garbage Grinder ( )
Showers ( ) — Cafeteria ( )
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. 1 ________________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_______/,0jotb------- G__S7i_-----A----- 4__ieX--------
'_..._,�___
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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
j llealt
Signed.._ _ � i.�.i.1J--------- G•----- ¢ � �°Z � I
Z D
Application Approved BY----?eefElo
-• • -- --------------•---•---------•----------------•-•-•----•----------•-••-- -�� ---- -ate--- •-----^--
Application Disapproved for ng re ons-.......................................... -•-•--------------------•---------------------------•-•---•••-...---•
-----------------------------------•--------------------•----.....---------------------------------------•--•---------••-•--------•------•-------- ---..............................................
Date
Permit No. --------------------------------------- Issu �___-_- - A9 126_L_..........---
Date
�FFAS 45 `8AIL.T 690 THE COMMONWEALTH OF MASSACHUSETTS
BOARD OF HEALTH
�J..<�.✓1�...... .......... OF......................................................................................
(Irrfifiratr of Tontp iattrr
CT, HIS IS TOERTIFY, That the Individual Sewage Disposal System constructed ( ) or Repaired
by'tti -___,... __1_1iS)-1 26..-----•-------------• -------•--------------------------------------.........__......---------------......--------------------....-----------------
Installer
at... /._ 3/. S]_EV ifI.Q-- -•--•-----------------•---------------------------------------------• ..................................
has been installed in accordance with the provisions of T'r r 5l
. of The State Sanitary, ode as ,describedii ( the
application for Disposal Works Construction Permit ti'o.__�_____________________ dated���.�4%_%1}-. ______
THE ISSUANCE OF THIS CERTIFICATE SHALL NOT BE CONSTRUED AS A GUARANTEE THAT THE
SYSTEM WILL FUNCTION SATISFACTORY.
DATE................................................................................ Inspector ::: , _ ..