HomeMy WebLinkAboutApp-Permit-ComplianceNo ...`.... ... Fps. '... `....
THE COMMONWEALTH OF MASSACHUSETTS
ARD OF HEAL
.. OF......- .... 1
Appliratilin for Disposal Works Toustrur#ion JIrrmit
Application is hereby made for a Permit to Construct ( ) or Repair ()4j an Individual Sewage Disposal
System at:
..
... �..... t9aN .... ...
pLoca ion............. i ---- ? ...... ...-Addressor Lot No.
Address
------
Installer Address
Type of Building Size Lot ............................ Sq. feet
Dwelling — No. of Bedrooms............................................Expansion Attic ( ) Garbage Grinder ( )
Other — Type of Building ............................ No. of persons......_...._.__............. Showers ( ) — Cafeteria ( )
Otherfixtures ------------------------------------------------------•-----------------------------------------------------------------------------.._.--------------
Design Flow............................................gallons per person per day. Total daily flow -------------------------------------------- gallons.
Septic Tank — Liquid' capacity......_.....gallons Length... ............. Width ---------------- Diameter ------------- ._. Depth ................
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 ( ) Dosing tank ( )
Percolation Test Results Performed by ....................... ................................... ------•------• Date .---------------------------------..__..
Test Pit No. I................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 ........................
Descriptionof Soil ........................................................................................................................................................................
............................................................. ------------------•--••••--•-•-•--•-----•-----••-------•-•----•--- -•---•---------------•---•••-•--••-----.....--------...................
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Nature of Repairs or Alterations
—Answer when applicable. 16 ... . .... .!� ..... ..............
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Agreement:
The undersigned agrees to install the aforedescribed Individual Sewage Disposal System in accordance with
the provisions of TITIE 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 of health.
SSI n
Application Approved By ....... �'V_
Health a-ffi-e�-----------------------•-----
Application Disapproved for the following reasons:_-_.----.--•-----.----•----------------------------------------
Date
.........................
Date
-------------------------
Date
PermitNo --------------------------------------------------------- Issued ------------------------------------•-------------------
Date
THE COMMONWEALTH OF MASSACHUSETTS
BOARD OF HEALTH
t.OF1.7'–d
..................i,.'J... ....
Tntifiratr of Toutplittnrr
THIS IS TO �$ IFY, That the Individual Sewage Disposal System constructed ( ) or Repaired
by 3 .�` d - --
--
at............��' 'i s` ............... a^ o ,p i F In..... r
has been installed in accordance with the provisions of TIT F r o The State Sani ry Cod as described ' e
application for Disposal Works Construction Permit No..'` ... .........�................... dated -------- ----- ------�_ ........
THE ISSUANCE OF THIS CERTIFICATE SHA 7 BE CONSTRUED AS A GUARANTEE THA THE
SYSTEM WILL FU TION SATISFACTORY.
/
vDATE..............................----••... Inspector --•-------------------------------------- -------------•---