HomeMy WebLinkAboutApp-Permit-Compliancey7No._------------- F�s......�. Sr .
THE COMMONWEALTH OF MASSACHUSETTS
BOARD OF HEALTH
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Appliratiun for 11spusal Surks Tonirur#inn ramit
Application is hereby made for a Permit to Construct
Systemat:
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-17
� n �� cation - Address
.... D.
Owner
Installer
Type of Building
) or Repair ( L4 an Individual Sewage Disposal
_...•--------------------------------••---...................._...«.............
or Lot No.
........ ..........•----------......---•--------------.........------.........................----
AddF.
es
Address
Size Lot____________________________ Sq. feet
Dwelling —No. of Bedrooms ---- cam...................................Expansion Attic ( ) Garbage Grinder ( )
Other — Type of Building ............................ No. of persons ............................ Showers ( ) — Cafeteria ( )
Otherfixtures ----- _-------------------------------------------------------------------------------------------------------------------------------------------
Design Flow..................................a5..gallons per person per day. Total daily flow ........_._._...._.._...__.__a2.0 ... gallons.
Septic Tank —Liquid* capacity ............ gallons Length ................ Width ................ Diameter ................ Depth ................
Disposal Trench — No ..................... Width ..... ;.............. Total Length .................... Total leaching area .................... sq. ft.
Seepage Pit No ......... i........... Diameter..... _�4_..._. 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 ..........................................................................................
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Nat�ure of RepairsorAlterations —Answer when applicable__.'t.:�&�
Agreement:`
The undersigned agrees to install the aforedescribed Individual Sewage Disposal System in accordance with
the provisions of LIT?.L 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. l
Signed.. i n�L:.YnC!-----..--- ? !_g
D to
Application Approved By .... --- -- . -----------------------------------•.....: •--•--•. 0//
------- / 4D. ...........
Application Disapproved for t e f oll ing asons:•---------•-....-•-------------••--••--•---._._.........----•---•-•-•-•---------------••----------•---..-----•.
......--•--...----•---•--------------------------------------------------•------------------------------•------------•----------•------- ------..............----------------
Permit No � - . �l .................................. Issued ._ U ( -IJ -'t .............Date
Date
THE COMMONWEALTH OF MASSACHUSETTS
BOARD OF HEALTH /
Tntifirttti of Tomplinurr
THI,Y IS TO CFjRTIFY,,�1}at the Individual Sewage Disposal System constructed or Repaired (C�
0 .410�2ls-1 _:,�2%
by ......... ........... • G _
at ........... 5. _Z / l... . ... ��
Installer
f®L /1/
has been installed in accordance with the provisions of TITLE 5 of The State .Saftary Code as described in the
application for Disposal Works Construction Permit No......................................... dated ............................ ..,...._.._.___._...
THE ISSUANCE OF THIS CERTIFICATE SHALL NOT BE -CON STRUE® AS A_GUARANTE15"THAT THE
SYSTEM WILL F--UU�NCTI
sN S ISFACTORY.
DATE.. .?.....................- ............... In I � ,�l
r�� .................