HomeMy WebLinkAboutApp-Permit-ComplianceFmc... .............
/1?2 ^ 13 THE COMMONWEALTH OF MASSACHUSETTS
p/J BOARD OF HEALTH T
See- BGG ---- • 77Z``'/ �....._.....OF.........7'�!.����1L1 G..! Z- ..................................
Apphration for Disposal Warks Tonstrnr#iun Errant
Application is hereby made for a Permit to Construct
S�stem at: -4T/
Loc tion - Address
--------------
Owner
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(A or Repair ( ) an Individual Sewage Disposal
.r.../7 ............................................
or Lot No.
Address
Installer
Type of Building
----------
Address
Size Lot...��_4��... Sq. feet
Dwelling — No. of Bedrooms ------------- �?__-_--------•---------_-Expansion Attic
( ) Garbage Grinder ( )
Other — Type of Building ---__-------------------- No. of persons ............................ Showers ( ) — Cafeteria ( )
Otherfixtures -----•---------------------------------------••----------•----•------------
Design Flow...............5 .................... gallons per person per day. Total daily flow ------------- __ .............. gallons.
Septic Tank —Liquid* capacity/_P e?�gallons Length...e........ Width ........... ` Diameter ................ Depth_.... _-.......
Disposal Trench — No ..................... Width--_ _...._._.. Total Length .................... Total leaching area -..---_---_-._--sq. ft.
Seepage Pit No ...... .�........... Diameter..._`6 �. Depth below inlet ..... --6........ Total leaching area.5.e
Other Distribution box (VQ Dosing tank ( ) _
Percolation Test ResultsPerformed �.._.L*J
_4sq.
-4—J4- .0/
by .... d �t___ L =_._
! � • Date--. .........
Test Pit No. 1 ---lt-----Z--------minutes per inch Depth of Test Pit ... .,
Depth to ground water' �Q �'� �•
Test Pit No. 2__ 5 . ...minutes per inch Depth of Test Pit ------ g _ r`.
Depth to ground water... _ ri......
----------•-----------------------•----•-••--•--•---••••---.....--- . .
Description of Soil----------- �1 ......... r!!.._ ..
...----- - - - - - - - - -
--------------------------------------------------------------------------------------------------------------------------------------------------------------•••-
Nature 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 TITLE 5 of the State Sanitary Code — The undersigned further agrees not to place the system in
operation until a Certificate of Compliance has bss d by board of health. �n
-•-• G• --•--•. 6'� ����f ..! -,L—
Signed...
D
ApplicationApproved By. -•--- ---• ---��•-------------------•---•-----....... ........................................ ---•------------------------------------
Date
Application Disapproved for the following reasons---------------•------------•---------------------------------------------------•--------------------------------
-------------•---------------------------------------------------- -------------------------------
Date
Permit ---------------------------- Issued_ ......
1'?-�J�'--•--� Z._...... -----------
Date
THE COMMONWEALTH OF MASSACHUSETTS
BOARC�QF„ HEALTH
.......................................... OF .....................................................................................
(9rdifirate of Touts haurr �=
TITIS IS'TO`C O-IFY, That the Individual Sewage Disposal System constructed ( ) or Repaired ( )
by w, --. 7,..,---- ---------- ------ ------------•---•--•-------------------------------------------...------------------------------
.}
Installer
has 'been installed in accordance with the provisions of TITLE _5, of The State Sanitary C`o&-as,deso.rib3eed in the
application for Disposal Works Construction Permit No ......................................... dated ------------- _------------------ ................
THE ISSUANCE OF THIS CERTIFICATE SHALL NOT BE CONSTRUED AS A GUARANTEE THAT THE
SYSTEM WILL FUNCTION SATISFACTORY.
T)ATE-Tnsnectnr ���