HomeMy WebLinkAboutApp-Permit-ComplianceNo.-��.�...� Fra/�1.r..........
THE COMMONWEALTH OF MASSACHUSETTS
BOARD OF HEALTH
......... ..............................OF..........................--•- ...................................................
Appliration for Bispoial 19orkfi Tontxnrtion Prrmit
ff /�Application is hereby made for a Permit Construct ( ) or Repair ( an Individual Sewage Disposal
1 System at :------. - .. ..........
................ j,.pT l�V ----- �'�''r�-(�.._.-
cation - Ad t or Lot No.
....................� ..... — — _ �.............................----.-..-.------------....------------------ -------------------------------------------
0 Address
...... • .........................
Installer 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. 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 .......................................................................................................................................................
...................... ----------------------------------------------------------------- ----------------------------------
-------------3-----------
-- ------ ---- ---
----- ------
Nature of Repairs or Alterations — Answer when applicable._____t_ _ _______ __ _ _ __ _________ _________ _
Agreement :
The undersigned agrees to install the aforedescribed Individual Sewage Disposal System in accordance with
the provisions of :TTL7 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.
Signed...................................................................................... ....................
Date
ApplicationApproved By-•••-•----•-•------•----------------•-•-••......-•---•------------......------....-----••••--_... -------------- -----------
Date
Application Disapproved for the following reasons: ....................................................................................................
----------------------------------------------------------------------------------------------------------•----•---------------------- ---- ------------ -------------------------------
Date
PermitNo ......................................................... Issued ------------------------------------------......--
Date
THE COMMONWEALTH OF MASSACHUSETTS
BOARD OF HEALTH
.......................................... OF .....................................................................................
C9rdifiratr of (lnntplianre
THIS IS T "TI That the Individual Sewage Disposal System constructed ( ) or Repaired (/`1
by---------------------- ...... ---......'• ....... .....-- ------------------------•--------.....----------...---............-----........---------.......•-•--
; Installer
has been installed in accordance with the provisions of TITLE 5 of Th tate Sanitary C e s described in the
application for Disposal Works Construction Permit No ---- Q__=_ _ _. .... dated---._ _. .2 � .... .........
THE ISSUANCE OF THIS CERTIFICATE SHALL NOT TRUE®. AS A G ARANT AT THE
SYSTEM WILL
FiJNCTIC N SATISFACTORY. �yf!