HomeMy WebLinkAboutApp-Permit-Compliancea
U
a
P�
a
W
W
x
Z
W
w
O
U
W
U
;d No/...0 ........--
THE COMMONWEALTH OF MASSACHUSETTS
FimB-/.f
-/-,BOARD \O%F` HEALTH
GCI. ---.OF .........
.,/..� ------ ................
Apptirtttilau for RaVv.ittt Work,5 Towitrurtiun Frrutit
Application is hereby made for a Permit to Construct ( ) or Repair () an Individual Sewage Disposal
System at: // 0-r- f _ ,
... 1.1._..�4d..T._....- .-.. .Jul..............................................................
Location - Address or Lot No. - ..._
...................... ............................................................................ .....--•-------...-----'------------•----------•-----•----•-•--------------•----------------------
Own .............. Address
.....................1TT� -'---- /,Tl..._._....... ------------- --------------- --------------
Install r Address
Type of Building 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........_._.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. l................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 ........................
Description of S
---------------------------------------------------------------------------------------•--------------------------------------
Nature of Repairs or Alterations —Answer when applicable " ___ __--__.'..... C _=. X.-•-..........• ..............
----------------------------------•---•------••------•---•-•••••---•---•-----•-------------------••---•-------------------------------•-•-----•••----•--------•-•-•----••-•......-•-•.....-•----------
Agreement:
The undersigned agrees to install the aforedescribed Individual Sewage Disposal System in accordance with
the provisions of TITiE 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.
Application Approved B
-------•-•-------- Date
PP PP Y --------------
Date
alth Office -
Application Disapproved for the Plowing reasons:----••-•------•-----....--••-------•--••-----•--------•------------••-----•-----•-•----••-•-•--•••-•-...........
------.•----------------------------------•-•---------------------------.....----•-.........------------. ••---------------------•--•--------•----•-------•-•-•----------•------•--••---•----------------
Date
PermitNo ......................................................... Issued_ .......................................................
Date
THE COMMONWEALTH OF MASSACHUSETTS
BOARD OF HEALTH
...................I......... .r:. n....OF...................................................................
hir�i�drtty,a� �u�t�titt�tr� "
THIS IS TO, CERTIFY, That the -Individual Sewage Disposal System constructed ( ) or Repaired
.,.i'r Installer
at. .._.:... ••-------------•---------------------•-------------------------•---• -----------------------
has been installed in accordance with the provisions of TIT 5 of The State Sanitary Code as described in the
application for Disposal Works Construction Permit No________ ___________<____________.__. dated___`: , r ._,,,�� X-_.__------------
THE ISSUANCE OF THIS CERTIFICATE SHALL NOT BE CONSTRUED AS A GUARANTEE THAT THE
SYSTEM WILL FUNCTION SATISFACTORY.
DATE..................... .......................................................... Inspector