HomeMy WebLinkAboutApp-Permit-ComplianceTHE COMMONWEALTH OF MASSACHUSETTS
BOARD OF HEALTH
...... ...................... ...... -OF ......................................
F:ss..l..®r...............
Apptiratinn for Mivaoal 10orkii Tonotrnr#inn pantit
Application is hereby ma a for a Permit to Construct ( ) or Repair an Individual Sewage Disposal
System at:
ocat2a,,Address or Lot No.
.................... . W! ........ ... . r._-i..�
/ Ow;er Address
7` 4k:..
.f .................................................. ...---......------------------•--•.............------..._..------•----•........................•--
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. 1 ..... _---------- 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 ______......_.__..______
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Descriptionof Soil -----------------------------------------------------------------------------------------------------------
............................................. ----------------------------------------------------------------------------------------------------------------------------------• ......
-------------- - ------ ----------------
Nature of Repairs or Alterations —Answer when applicable_Pl.i-7___.______.,[..,,.
Agreement:
The undersigned agrees to install the aforedescribed Individual Sewage Disposal System in accordance with
therovisions of :ITS
p 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
Application Approved B 6,_-.. ........................................
....................Date ----
Application Disapprove o i }iif&Migglreasons:------------------------------------------------------------------------------------------------------
-••-•---•-----•-•-----•----------•-------•-•-------•------------•-•---•-----------------•--•------------•------•-------•-------------•-•--••----•--------------------------------...---•------
Date
PermitNo --------------------------------------------------------- Issued_ .......................................................
Date
THE COMMONWEALTH OF MASSACHUSETTS
BOARD OF HEALTH
.......................................... OF ....................................................................................
Trrtifiratr of Tomplianre
THIS IS TO CERTIF�K T the Individual Sewage Disposal System constructed ( ) or Repaired (3�)
z; . Zt....__.----
. r Installer
at .................... ��'.6.I---------- -- - '/_7
------------ ---•--------------------------- •---- ----- --- ----.....------------
has been installed in accordance with the provisions of TI F 5 of he tate Sanitary Code s d -�}' ed in the
application for Disposal Works Construction Permit No.._..._ ........ dated-_ v' /_ ......•..........
THE ISSUANCE., OF �tHIS CERTIFICATE SHAL NOT BE CONSTRUED AS A G RANTEE THAT THE
SYSTEMA WILL FUNCTION SATISFACTORY.
DATE............................................ =................................... Inspector ....................................................................................