HomeMy WebLinkAboutApp-Permit-Compliance" No. 3 L FEB........
THE COMMONWEALTH OF MASSACHUSETTS
BOARD OFF/—HEALTH
y�
... ......OF .............. . e�.
Appliratiun for fliupuuttl Works Tanstrurtiun 1rruti#
Application is hereby made for a Permit to Construct ( ) or Repair V-1)"an Individual Sewage Disposal
System at:
....... ...... Vfc_s _-� �ft/Fs.--..� ......... l✓ Iv_'C r� 5- •-i�v :............ . . .. l u>!or�,
t
T or Lot No.
ion -ddress
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Owner Addre
...................... ,.. —C w ..................................... .......................................... g:cl..
Installer Address
Type of Building Size Lot ............................ Sq. feet
Dwelling —No. of Bedrooms ................ 3.__..._...__•.........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. 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---..... ...--------------------------------------------------•--•----•-----•---•-- ....... ---• ------•--- ..... --•.-• -•--- .....
Na7t je epairs or
l -a-----------
Agreement:
------------------------------------------------------------------------------------------------------------•--------•--.......C. S.
Alterations — Answer when applicable ......... `% ......... o- o X A .................. _._-2. _
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 b d by the b si of health.
Signd... ----••--•----- -----------------------------
D t,��
ApplicationApproved By---•--------•-••-•----• . •--- ....... ........... ...................................... .... •.•..•.
Date
Application Disapproved for the following reasons.--------•---------------------•---....-------•--....---------------------•----• ......---------------•--.
(� - Date
Permit No... ._..- ....-•................................ Issued- ........... - -`�
ate ---•---..._......
THE COMMONWEALTH OF MASSACHUSETTS
BOARD 0,F HEALTH
r�..'!........ .......... OF ../ ,CSG'
.......... o.lw%...............................................
Trrfifiratr of Toutplittnrr V
THIS IS TO CERTIFY That the Individual Sewage Disposal`, System constructed ( ) or Repaired
C� Cj fi ,l,f
by -
s ...._...,�.... r -•----• ..............•------••--------•---•-•-••............-•--- •--
�. x� � �/ • , , / nstaller
----- ------------------------------ ------------------
---- -- - -- -
has been installed in accordance with the provisions of TITIN 5 of The State Sanitary Codas described in the
application for Disposal �'Vorks Construction Permit No..._� 'K.- -_ � j -------- dated...._......................
THE ISSUANCE /OF THIS CERTIFICATE SHALL NOT EE CONSTRUED AS A GUARANTEE THAT THE
SYSTEMA WILL,FUNtTION SATISFACTORY.
DATE---- �' `� ,' Inspector.......................... �..`
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