HomeMy WebLinkAboutApp-Permit-Compliance.. y
No.-13� Fss......f S
THE COMMONWEALTH OF MASSACHUSETTS
BOARD OF HEALTH
...................... .................... OF ..........................................................................................
Appliration far Uispv.5 tl Works C9lanatrurtiun 1hrutit
Application is hereby made for a Permit to Construct ( ) or Repair (P-lan Individual Sewage Disposal
tem at ._ =- - - ...�_�_ . ' _ .... .----
Location - Address % or Lot No.
................ —.... --__—...................................................................... -...._._._.........•-•--------------_......•-•---••--------•---------..._......._..............._
Owner Address
W
Installer Address
Type of Building Size Lot ........ ...... Sq. feet /
aDwelling — No. of Bedrooms ........ .-3 .............................. Expansion Attic ( ) Garbage Grinder ( )
P4 Other — Type of Building ____________________________ No. of persons ............................ Showers ( ) — Cafeteria ( )
Pa Other fixtures .._._....---•------------------------------------- .
W Design Flow .............. 5'�5 ---------------------- per person per day. Total daily flow .......... .__.sa.............. gallons.
WSeptic T7, Iuid ca pacitv.�R9o.gallons Length ................ Width_______________ Diameter ................ Depth ....... _------
x Disposal Trench No. ___„l ............. Width_____________ Total Length ... ZC,=....._. Total leaching area__JR.
Seepage Pit No ..................... Diameter .................... Depth below inlet .................... Total leaching area .................. sq. ft.
Z Other Distribution box (�. Dosing tank
'-' Percolation Test Results Performed by.__C� ---- �_ 'y. W.GL _./z :_. Date
inch h f s Pi
,.a Test Pit No. L.-w--2—minutes per Dept o Tet t/ yY..____ Depth to ground water...,-'
f� Test Pit No. 2................minutes per inch Depth of Test Pit .................... Depth to ground water ........................
a' --------------------------------------------•------••----•- -•---------•---••
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0 Description of Soil _••------ — E .---- 9�7 � `'�� L-7
W
W--•--•------••-----•-- -------•------------------•---•-•••--•---•---•------•---••--•-•---•----•----•-•----------•-•---------------------••-------•---------------•-•-••••-•-•-...__.......-•------••--
UNature of Repairs or Alterations — Answer when applicable ...............................................................................................
--••--•-----------••----------------------------•-------•----------------------------•--------------------------------------------------------------------------.-:-.------- ..........................
Agreement:
The undersigned agrees to install the aforedescribed Individual Sewage Disposal System in accordance with
the provisions of TIT1Z 5 of the State Sanitary Code — Trbe undersigned further agrees not to place the system in
operation until a Certificate of Compliance has be the oard of health. �p
Signe - /�' --------
Application
D
Application Approved By--------•t----------........................................................... .��r/
Date
Application Disapproved for the f ollo ng rea ons----------------------------•---•----...-------------••--------...----------------------•--------------......._._
PermitNo .......... P- 3 ................................
Date
Issued_ .... - -•--•----------------
Date
THE COMMONWEALTH OF MASSACHUSETTS
BOARD OF HEALTH
.......................................... OF .....................................................................................
(Ur#ifirat a of Tompliaurr
THIS IS TO CERTIFY, That the Individual Sewage Disposal System constructed ( ) or Repaired ( )
by------- ---------•------------____--------•------•----•--•------ --------------•---------------•-----•-••---••----•••••------------------------------------•----•-----•--_-----•---------_--
Installer
at•-••-------- ___-----•----------------------------------- ------------------•----------------------- -------------•--------••-----•--------
has been, installed in accordance with the provisions of TITIZ 5 of The State Sanitary Code as described in the
application for Disposal Works Construction Permit No_________________________________________ dated ............................ ....................
THE ISSUANCE OF THIS CERTIFICATE SHALL NOT BE -CONSTRUED. AS A GUARANTEtTHAT THE
SYSTEM WILL F CTION SATISFACTORY.
DATE ......... :.....: .... Inspector - /