HomeMy WebLinkAboutApp-Permit-Compliance_1 1
.; 4 L' `P]s
oJe�re .i ..l� u�ay
THE COMMONWEALTH 6F MASSACHUSETTS
BOARD OF HEALTH
...........................................OF......................................._..................................................
Appliration for Disposal Works Tonstrur#ion 1rrutit
Application is hereby made for a Permit to Construct ( ) or Repair 'i) an Individual Sewage Disposal
System at:,rte .,,^. e I- � ! C Z( E
............................ ..... U" lfa � .J.--•--........... ................................
or
, 1 e ............................ ............................................ Lot -.No.
......................... ........ .......
....5
-----------------Owner ....... ................. .................................................. .Address -................._............._..
... . ._... ........
Installer Address
Type of Building Size Lot .... _.Sq. feet
Dwelling — No. of Bedrooms.........................•..................Expansion Attic (V -r 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 ------------------------•---------------•---------------------------•------•----------
.--•----------------------------------------------------
..-------•-----------------•-------...._..------------------....--•------------------....----.............--------- /--------•--- ._........•-------------.......---•--------------.....
Nature o e airs or Alter tions — Ans er when a cable.....,__._, .rlG? Sl.... l•S_............................
p
p3 / ! ..'......�-------------PL"�/¢� 31 ...:... 4 ---••--•--
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 the board of health.
Signe
Application Approved .......................................... ..... is ._lu........
Date
Application Disapproved for the following reasons:-•-•---••--•...............•----•---------•-------••----------•---..........----••------....---------•----_.....
.........-•---------•---•----•--•-----------•----•-------••------•------------------•---•I--••----...-••---......---=-•---.......--•-------------=---------•--.........--------•-.
//te�rr,, ate
Permit No.....55—.215 --------------------------- Issued......-3.� ..l.Q ...................
Date
T THE COMMONWEALTH OF MASSACHUSETTS I �Y
BOARD OF HEALTH
.......................................... OF ..................................................................................
Trr#ifirne of Tontplinurr
THIS IS TO CERTIFY, That the Individual Sewage Disposal System constructed ( ) or Repaired O
Installer
at ......... ...
................
------------ -•------_....----------------------.........--_--.-------------------------.------------•---------------
has been installed accordance with the provisions of TITLE 5 of The State Sanitary Code? described in the
application for Disposal Works Construction Permit No...` �`�. g ................. dated__ -:7 1225 ...................
THE ISSUANCE OF THIS CERTIFICATE SHALL NOT BE CONSTRUED AS A GUARANTEE THAT THE
SYSTEMA WILL FUNCTION SATISFACTORY.
DATE....._.: ??. LO ............................................................ Inspector.... ..... .........---•----.............----•-.