HomeMy WebLinkAboutApp-Permit-Compliance� Y s
THE COMMONWEALTH OF MASSACHUSETTS
BOARD 0'ALTH r
............... OF ..... ...................................................................................
Appltrattun for Disposal i0orksTonstrurtion f rrmtt
j9n is hereby made for a Permit to Construct ( ) or Repair ( ) an Individual Sewage Disposal
Ag-
_..- ----- --------
1 Location - Address
Installer
Type of Building
Dwelling —No. of B/..k_
s...
Other — Type of Bui......
Other fixtur
Design Flow ....................................... Ions
Septic Tank - Liquid' pacity-----------gall s
Disposal Trench — No .................. Width.-. _
Seepage Pit No----------- -------- iameter._...._......
Other Distribution box Dosin
Percolation Test Results Performed by...
Test Pit No. 1................minutes per inch
Test Pit No. 2................minutes per inch
--------------- - -CST= !� 5 -nom P.:aQ............--
--......... _ ----------- ------------ ------ ---
................ 7. .a-.-------------------____._..._.-
dress
----------------------D tuL``....--------------------------.---------------
Address
Size Lot ............................ Sq. feet
. .................Expansion Attic ( ) Garbage Grinder ( )
No. of persons ............................ Showers ( ) — Cafeteria ( )
-•...................................-•------------------------........--------------------------------------------------
per person per day. Total daily flow....................,.......................gallons.
Length ................ Width................ Diameter................ Depth................
.............. Total Length ..................... Total leaching area ...................sq. ft.
...... Depth below inlet...... .............. Total leaching area .................sq. ft.
tank ( )
---------------•--------..............----....--------•--------------• Date . -----------------------------------
Depth of Test Pit .................... Depth to ground water........................
Depth of Test Pit .................... Depth to ground water........................
Descriptionof Soil--------------------------------------------------------------------------------------------
---------------------------------------------------------------------------------------------------------------- ---1 -----
Nature of Repairs or Alterations -Answer when applicable .... .._...../__J__._---..........................................................
Agreement:
The undersigned agrees to install the aforedescribed Individual Sewage Disposal System in accordance with
the provisions of TITL% 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 health.
Signe . t�/-- % e�
d Da�j�-7.
ApplicationApproved By--.----- .......... -•----------------------------•-----....------......._..........-- -• - D--. -••--
Date
Application Disapproved for the f ollo 'ng reasons----------------•-------------------------------------------•----................----••... ._....
..�D+ate
Permit No.91--- -- - - ----_.�. Issu - - .di?.! .........
Date
THE COMMONWEALTH OF MASSACHUSETTS
BOARD OF HEALTH
OF..� :/�.�. ...............
Trr#ifuttb of Toutplinurr
THIS IS TO ,CERT hat tile Individual $ age Disposal System constructed ( ) or Repaired (!
ryas peen installed in accordance/with the provisions of TITLEE of The State Sanii
application for Disposal Works Construction Permit No .$ L____Q__ _____________ dat
THE ISSUANCE OF THIS CERTIFICATE SHALL NOT BE CONSTRUED AS
SYSTEM W ,1� :U TION SATISFACTORY. �---•--`-``
1 lS h �9
DAT ..:.. --- - f ------------------------------- Inspect?C�4 10
as..de-scribcd in the
THAT THE