HomeMy WebLinkAboutApp-Permit-ComplianceFas.......1_ 1.
THE COMMONWEALTH OF MASSACHUSETTS
BOARD OF HEALTH
.........OF...... .........................................
Appliratiun for Disposal Warks Tonotrurtiun rmit
Application is hereby made for a Permit to Construct ( ) or Repair ( ) an Individual Sewage Disposal
System at
.-.1 .. o... ... ..... ................ ....... 4 T... w ! ......... ? r� P e" . .........._......_..._....
ion -Address or Lot N -
4r,Clc.......................... ..../J_d`...�
nerAddre/ ss
...................................... .... Q.. ® .�C.... � ,.-.r. -i..
Installer Address
Type of Building Size Lot ............................ Sq. feet
Expansion Attic Garbage Grinder )
Dwelling —No. of Bedrooms .................. p ( ) g
Other — Type of Building ............................ No. of persons ......... ................... Showers ( ) — Cafeteria ( )
Otherfixtures ................ .......... ..... ............... .............. .•--_..... -............................. _......................................... _.......
Design Flow .... - ....... 74...6.:..Ph.._..... gallons per person per day. Total daily flow ........ S-� a.....................gallons.
Septic Tank — Liquid capacity...... ...... gallons Length ................ Width_ ............. .. Diameter ................ Depth ................
Disposal Trench — No. o ................... Width ..... Total Length. ................... Total leaching area-... sq. ft.
Seepage Pit No ........ 46......... Diameter ... ....1,t�........ Depth below inlet.._ Ai' .... Total leaching area .' ......sq. ft.
Other Distribution box ( ) Dosing tank ( ) -94%(5 �) od
Percolation Test Results Performed by..........................
=._r . . .......... Date ........................ --..............
Test Pit No. I................minutes r inch Depth of Test Pit ........._.__._.. `',x`.Depth to ground water........................
Pe
--
Test Pit No. 2................minutes per inch Depth of Test Pit .................... Depth to ground water. .......................
....................:...................................... ........... ----•. -......... ........----------
Description of Soil ... ....... /ll'.e��......?. t ..... C..a ...-• =----
................. -......................................................................................... -..................................................... -.__..........----•-•-•------...._..
---•--------------------••-•-------•--••-----..............---•----...--•--.........-•-....••.---•- _0.
Nature of Repairs or Alterations — Answer when applicable_. e_!.✓..V!� ..
Agreement: A.
The undersigned agrees to install the aforedescribed Individual Sewage Disposal System m a`ceordange 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 beep iksued by ft boardAof health.,
Application Approved By. ............... ............. .! --- ..
'i ate
r
Application Disapproved for the following easons:... . :
....................•----............................................................ - ............. ----••-•--....-•--••-------------------•-----•--.---• .......... t.....--. -_
Permit No....-� ?-----------------_.._...... Issued......-..._..� - � � D�---
THE COMMONWEALTH OF MASSACHUSETTS
BOARD. OF HEALTH
............................... ..?......OF .......... ::.:.f.� ..... ......... ,..... ...
Tiertifirate ,af, Toutpliana
XHIS IS •TO CERTIIFY;" That the Individual Sewage Disposal System constructed ( ) or Repaired
. �• ` ` ............... •... . -_.................... ..... ..............•-•_._... _ ....
r \ / Installer
f/
..................................... ......... ...................... .......1 ...
has been installed in accordance with the provisions of TITLE. - 5 of The State Sanitary .Code as d�cribed�iothe
application for Disposal Works Constructio'O"''ermit No.. -..2d ....... ,..:..: ..... dated ...^.: ' ',.._. ...........
THE ISSUANCE OF THIS CERTIFICATE SMALL NOT BE CONSTRUED AS A GUARANTEE, THAT THE
SYSTEM W�LL FUNCTION SATISFACTORY.` r
F
DATE.,.-..'.. . .. ........--.`.... ....... ......._..... - Inspector.