HomeMy WebLinkAboutApp-Permit-ComplianceNo&�Lk .... Fnn.. d?.....US....
THE COMMONWEALTH OF MASSACHUSETTS
BOARD/ OF HEALTH
.......
�' _. _ .............0 F.... L...................................................................................
............ .
Appliration for Diripwial MirLi Tumdrnrtion ramit
Application is hereby made for a Permit to Construct ( ) or Repair ( ) an Individual Sewage Disposal
System at:
a.. - S `4 =--------------•---------------..._� T ` ............ .Mnp_.ca.------------------
Lotntim� - Address // or Lot No.
13��� ........ ----•---1``'l`i ;r�7........................ .................... ............ ................................. ............
Owner Address
I nstakr 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. 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_ ....... ...: .............. ..---- 2.
..... .--
Nature of Repairs or Alterations — Answer when
Agreement:
The undersigned agrees to install the aforedescribed Individual Sewage Disposal System in accordance with
the provisions of TITIZ 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. p�
.....................................
D
.............................
Application Approved By.... G .-.! \lhi� ......--...._........- --....... `2 ......--......
Date
Application Disapproved for the following reasons: .......... ................ ........... .............. --......... ........ ............... _...........
Permit No ..... h�.
.................................
Datt
Issued_... �1 ! g`� ..._. ...............
THE COMMONWEALTH OF MASSACHUSETTS
BOARD OF HEALTH
.........................................OF....................................................................................
Trrtifirate of Tompliaure
THIS IS TO CERTIFY, That the Individual Sewage Disposal System constructed ( ) or Repaired
Installer
has been installed in accordance with the provisions of TITLE J` of The State Sanitary Code as escribed 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.
DATE........ +_ ?.. %............................................. Inspector---- ------------.....---------........................................