HomeMy WebLinkAboutApp-Permit-ComplianceTHE COMMONWEALTH OF MASSACHUSETTS
BOARD OF HETH
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Fics�L ....
Appilration for 11isposa1 Works Tonstrurtion Vgruttt
Application is hereby made for a Permit to Construct ( ) or Repair ( an Individual Sewage Disposal
System at:
:........................ «w .. -«Y
Location - Address or Lot No. -•««
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ess
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Installer ddress
Type of Building Size Lot ............................ Sq. feet
Dwelling — No. of Bedrooms............................................Expansion Attic ( ) Garbage Grinder ( )
Other —Type of Building ............................ No. of persons............................ Showers ( ) — Cafeteria ( )
Otherfixtur s ------.............................-•--•-------------------.....................--•-----•-•-•---•..................--•-
Design Flow ..... 25Z.._ ...................gallons per person per day. Total daily flow........ ....C? ................... gallons.
Septic Tank—Liquid-capacity---/.......gallons Length .....%-....... Width.......... Diameter ................ Depth ................
Disposal Trench—o ..................... Width.................. Total Length .................... Total leaching area ................... sq. ft.
Seepage Pit No ....... _f ............. Diameter........'— . Depth below inlet .._.... V _... . 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........................
Descriptionof Soil -------------•---------•-------------------------------------------------------------------------------------------
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Nature
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Natureof Repairs ar� Alterations — Answer when applicable..--.. -�� ±'� ----------- ...... L.�...... .•._ ......
`P .... �-- - � ihc�........_� -P� ��� �c��ll� -ice.
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 tIN board of Lie
11th, R
Application Approved By
Application Disapproved for the
Permit No.-f...-�
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Issued . . L." 1J .1.... _
D�ate
THE COMMONWEALTH OF MASSACHUSETTS
BOARD OF, -HEALTH
J
&rfifiratr of Toutpitunrr
THIS IS TO CERTIFY, That-the_Inciividual Sewage Disposal System constructed ( ) or Repaired
by................«.y , :::� �......... ..:..tt.1....� {'................. -................................................... ...................... «........ .
Installer 5 r L
has been installed in accordance with the provisions of TtTI. f The State
application for Disposal Works Construction Permit No.�1__ :.�� al---------- ------
THE ISSUANCE OF. THIS CERTIFICATE SHALL NOT BE CONSTRUI
SYSTEMA WILL FUNCTION SA CTORY. f
DATE - = '- s�. , ....----......... In
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