HomeMy WebLinkAboutApp-Permit-ComplianceNo_-X-��M(-2
THE COMMONWEALTH OF MASSACHUSETTS
BOARD OF HEALTH
of�4� O%1. . -----------------------------------------
Appliration for Disposal Murks Tons tran
n 1rrutit
Application is hereby made for a Permit to Construct ( ) or Repair (ndividual Sewage Disposal
System at: y�-•� l
..... , .`�.^..J.. .`.'{.........•................
...:.A
�y _ ner
4J
Installer _ �
Type of Building
Dwelling — No. of Bed
Other — Type of Build
Other fixtures
----- - - � IJT lea 7 m410- .........a
or Lot No.
.... .......................................................-
�_/%%���> ',C41�/ Address
(�(/ ....... ---------------- *..................
-........
Address
Size Lot____________________________ Sq. feet
..Expansion Attic ( ) Garbage Grinder ( )
No. of persons ............................ Showers ( ) — Cafeteria ( )
Design Flow......................UDiame
per person per day. Total daily flow ............................................ gallons.
Septic Tank —Liquid' ca.- gall s Length ................ Width ................ Diameter ................ Depth ................
Disposal Trench — No....idth... ............... Total Length .................... Total leaching area .................... sq. ft.
Seepage Pit No.................r................... Depth below inlet .................... Total leaching area .................sq. ft.
Other Distribution box (Dosin tank ( )
Percolation Test Resultsrmed by ........................................................................... Date ........................................
Test Pit No. 1................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........................
----- ---------------------------------------------------
-.....
------------------
' Description of Soil --------------------------------------------------------------------------------------------
.................. -•----•---------------------------•-------------...........---....----------------•--------- •. q y_�..�
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'Al TI.S 5 of the State Sanitary Code — The undersigned further agrees not to place the system in
operation until a Certificate of Compliance has been iss ed by the board health.
Signed. --- `�
Application Approved By
Application Disapproved f
Permit No ............ ---_ I -
---.."T.._ ._ � "
"
Date
----•-------•------•-------•------------------•------------•-----------
ate
Issued ......... .... .... .........D
Date
THE COMMONWEALTH OF MASSACHUSETTS
BOARD OF HEALTH
.......................................... 0F. �/..,6'�..A4 2. ...................................
Trrtifirate of Toutpliunre
THIS IS TO FFM�
a In�vid'ual Sewage Disposal System constructed ( ) or Repaired (t/�
by. ..........:... ..... - ..........------ .----------....---.......----.............•........--------•----•----...............I......
has, been installed in accordance with the provisions of TITIN 5 of The State Sanitary C de a escri�bj in the
,...application for Disposal �?V.orks Construction Permit No.....� � .. dated._... c'. ---------
THE ISSUANCE OF THIS CERTIFICATE SHALL NOT BE CONSTRUED AS A GUARANTEE THAT THE
SYSTEM WILL FUNCTION SATISFACTORY.
_.
DATE... �...Ya... Z- -)
--I "` 0l ................... Inspect r�&..`.. .. :S._.1