HomeMy WebLinkAboutApp-Permit-ComplianceNOE--
/ THE COMMONWEALTH OF MASSACHUSETTS
BOARD ORZ HJ EALTH
L..®L1,Jj OF .... .........../----------._..............
Appliration for Elispao sial nrk�i Tomitrnrtion Vamit
Application is hereby made for a Permit to Construct ()) or Repair ( ) an Individual Sewage Disposal
Type of Building Size Lot,/1.,,!_......Sq. feet
Dwelling — No. of Bedrooms .............. --------- :.............. Expansionattic ( ) Garbage Grinder
Other — Type of Building ______•—___ __________ No. of person s._._......_9............. Showers ( ) — Cafeteria
Otherfixture .------•----------------------•-------------•--•---------------------••------------ -•---------
Design Flow............ ____.....• .........:...gallons per person per day. Total daily flow ............ ......................... gallons.
Septic Tank — Liquid" ca.pacity.I allons Length ..... ___."'—_... Width ..... ----..... Diameter__- ----------- Depth .._...... .__.
Disposal Trench — No .......... ...... Width ...... f_.. _.... Total Length .... •- _-..-...... Total leaching area ........ ...--sq. ft.
Seepage Pit No -_..._1_._____--•- Diameter ..... /®....... Depth below inlet ...... 4'......... Total leaching area_. _0..s . ft.
Other Distribution box (X) Dosin tank Ase
Percolation Test Results Performed ... Date ...... ±_ %t _____________
Test Pit No. 1 ------......minutes per inch Depth of Test Pit.....13Z._------ Depth to ground water.....? ..........
Test Pit No. 2................minutes per inch Depth of Test Pit .................... Depth to ground water ........................
----------------------------- ----------------- ...... :11.
Description of Soil ----49--= 6 •-•---.7�Q � .4 ----------- -�_1��C-UYIZ"f--------�------...................
--......vOVUM...S6,40--------------------------•----------•----------....---------------------...-----•---------------•--------------...---.•...---...----------------
--------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------
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 J.TT=
5 of the State Sanitary Code — The undersigned further agrees not to place the system in
operation until a Certificate of Compliance has bee sued by the board of health. -
Signe ---- ��/ ,�G,Z�10 l�
(� /ate
Application Approved By--_I�-• ---------- ----••---------------------------------------•--•-•-•----------- ...-•••-•---
Application Disapproved for the following reqs ns---------------------------------------------------------------------------------------------------•-------------
---------------------------------------------------------------------------------------------------------••------•-••-----------•----•-•-----------------. ----------•--•-•------••----•-•--------------
Date
PermitNo --------------------------------------------------------- Issued ------------------- ....................................
Date
1'
THE COMMONWEALTH OF MASSACHUSETTS
BOARD OF HEALTH
....................... .......... I........ OF ....................................................................................
dw
Tntifiratr of Toutpliatta
THIS IS T CE � FY, That the Individual Sewage Disposal System constructed��`) or Repaired ( )
''r --------------------- -------------- ------------------ --------------------
at....... ------ IGS-�.. ---------
has been installed in accordance with the provisions of TI"' T' Sof Th state Sanitar Code des t*bed in the
application for Disposal Works Construction Permit No._'__'_ dated. __ �2 ___%....___._...
THE ISSUANCE OF THIS CERTIFICATE SHALL NOT BE CONSTRUE® AS A G RA EE TH THE
SYSTEM WILL FUN TION TiSFACTORY.
DATI............ / ���- ...... ----------------------------- Inspec ... ...... .... .... .....-. ..... ...........