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Home My WebLink AboutApp-Permit-ComplianceFEB ...... ;R .... ('-e,11THE COMMONWEALTH OF MASSACHUSETTS BOARDPF HEALTH .Apure#ton for Btopoutt1 Works Pastrurtion Frrutit Application is hereby made for a Permit to Construct ( or Repair ( ) an Individual Sewage Disposal System at ----------- '.:_�/ ......................... .................. . ex . ��..---...----.----------... 1 • © Location -Address - or Lot No. - ...................... ............................................................................ --__------------------------------------------ Ow er Address -------------------- ^yy_ �` - ------------------ * ------------------------ --'---•................................... Installer Address Type of Building�/ Size Lot_ .7.Y ... Sq. feet Dwelling — No.' of Bedrooms________________ 54 .................... Attic ( ) Garbage Grinder 1�14 Other — Type of Building ____________________________ No. of persons ............................ Showers ( ) — Cafeteria ( ) Other fixtures --------------------------------- - Design Flow ................... l/_ ............. gallons pe pn e;Py Total d it,y fl-'-._-_--_•_ 1 Septic Tank — Liquid capacity/gallons Length.R......... __________ Width__(_e__ Diameter________________epth_— _L�t__- 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 (t%T Dosing k ( ) Percolation Test Results Performed b __ .45_C . -:-�cDate., Y --------------- Test Pit No. 1__4_2__ .... minutes per inch Depth of Test Pit ... /oi__ Depth to ground water________________ _______ Test Pit No. 2 ................ minutes per inch Depth of Test Pit .................... Depth to ground water ........................ --------------------•--•------•--------------------•----------------•-----------...-----------_.....--•••--' Description of SoiL<2^Z �•�'`�-'•'-� ---�--------------_._.. z__ ---- .5�g'°?,y`,''S�'y 4)t _-----J------_----------- ................. ------_---------- Nature of Repairs or Alterations — Answer when applicable ----- ------- ___ _---_-_-------------_---------•------- . 1- ! ! = Agreement: The undersigned agrees to install the aforedescribed Individual Sewage Disposal System in accordance with the provisions of TITIN 5 of the State Sanitary Code — The undersigned further agrees not to place the -system in ope tion unti C - -�ColiWZcefi�en iss ed by b d --M health. Application Approved By.... ..- - --_ �pplication Disapproved for the following reasons:-----------------------•------•-------•------------------------•-- Date ate ------ ----•-•---------------•-•--------------••-•---•----------------•---------------------•---------------------------------------------------•-----•---------------•-----------•-----------------•--- Date Permit No..... -----------------------• Issued------ - j Date r THE COMMONWEALTH OF MASSACHUSETTS BOARD OF HEALTH ..................... .'.- OF...._.. ........._...; ..: ............................................ Trtifiratr of ToutpHaurr THIS IS TO CERTIFY, That the Individual Sewage Disposal System constructed or Repaired ( ) by-----. s _...__ _.... '".:::: a : z----- -- ---------------------------------------------------------------------------•------------------- - } Installer y ,_ --------------------------------------------------------------------------------------------------------------------------- has been installed in accordance with the provisions of TITLE 5 of The State Sanitary Code as described in the application for Disposal Works Construction Permit_________ dated___.___._'__:_ :__:__:_:_ >=-- _ ________________ THE ISSUANCE OF THIS CERTIFICATE SHALL NOT BE CONSTRUED AS A GUARANTEE THAT THE SYSTEM WILL FUNCTION SATISFACTORY.