HomeMy WebLinkAboutApp-Permit-ComplianceNo._� ... �/ �s Fac ........
THE COMMONWEALTH OF MASSACHUSETTS
BOARD OF HEALTH
................ _...................... O F...................................__................._......._.......................
Apptiration flax Bi"oiittl Works CDon,aUurtion Vtrmit
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 TITLE 5 of the State Sanitary Code — The undersigned further agrees not to place the system in
operation until a Certificate of Compliance2easons:
been issued by the board of health.
Sig'.�..r'f>'/ .,>=•G: ... �i -----------....9"`�Application Approved By.. i��-'-----�.. --........... ........... .. �-/ �`Data
Application Disapproved for the follo' ing ................ .......... ......................... ............ :.tts:� -.-----......--•-
.................. .................... ..•--.....----........--------...........................---•--•...... ---.............. -- '-------- - .............---.......................
PermitNo...._...._ a...........-•--------------------------- Issued.--------� ---q---�--�t'-----•--.........--------
Date
THE COMMONWEALTH OF MASSACHUSETTS
BOARD OF HEALTH
..................................... I.... O F... ............................................. ................................
Trrtifiratr of Tomptian-6
THIS IS TP CERTIFY, That the Individual Sewage Disposal System constructed ( ) or Repaired 4__�r
- - -- ..........................................••............
--
Installer
has been installed in accordance with the provisions of TITLE 5 of -The State Sanitary Cqd as described in the
application for Disposal Works Construction Permit No...._f_:.... . _... .............. dated.....:r'..r�e .... L,' �...............
THE ISSUANCE OF THIS CERTIFICATE SHALL NOT BE CONSTRUED AS A GUARANTEE THAT THE
SYSTEM WILL FUNCTION SATISFACTORY.
DATE.........................::.................................---..... Inspector....---....--------......_•-----------................................
Application is hereby made for a Permit to Construct ( ) or Repair ( ) an Individual Sewage Disposal
System at:
-•--- ' L ..Jive.........
'> ... � ..................... 1_xP..1--..M a a:2-?>
Location - AddressG,r ,.
1<........................................� -... --............ .............
or, Lot No.
Owner-+
7
TAddress
Installer
Type of Building
Address
Size Lot ............................ Sq. feet
U
Dwelling—No. of Bedrooms............................................Expansion Attic ( ) Garbage Grinder ( )
Other—Type of Building ............................ No. of persons............................
Showers ( ) — Cafeteria ( )
PqOther
fixtures ....................... .....
Design Flow............................................gallons per person per day. Total daily flow ............. ................ ............... gallons.
W
WSeptic
Tank—Liquid capacity ............ gallons Length_ .............. Width ....
............ Diameter................ Depth ...........
x
Disposal Trench — No ..................... Width .................... Total Length ....................
Total leaching area .................... sq. ft.
Seepage Pit No ..................... Diameter .................... .Depth below inlet....................
Total leaching area .................. sq. ft.
2
Other Distribution box ( ) Dosing tank ( )
Percolation Test Results Performed by .......... ___ ................ ..................................
Date .......... ...................
aTest
Pit No. I................minutes per inch Depth of Test Pit....................
Depth to ground water........................
f
Test Pit No. 2................minutes per inch Depth of Test Pit....................
Depth to ground water........................
a.....................................................................................
O
: J . ..... .......---------..........-•----.----..............
Description of Soil .... --•................... _................... ----•-------------.............. .G<°l.?t:::.f l.Y-----........ - __ .-.......
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 TITLE 5 of the State Sanitary Code — The undersigned further agrees not to place the system in
operation until a Certificate of Compliance2easons:
been issued by the board of health.
Sig'.�..r'f>'/ .,>=•G: ... �i -----------....9"`�Application Approved By.. i��-'-----�.. --........... ........... .. �-/ �`Data
Application Disapproved for the follo' ing ................ .......... ......................... ............ :.tts:� -.-----......--•-
.................. .................... ..•--.....----........--------...........................---•--•...... ---.............. -- '-------- - .............---.......................
PermitNo...._...._ a...........-•--------------------------- Issued.--------� ---q---�--�t'-----•--.........--------
Date
THE COMMONWEALTH OF MASSACHUSETTS
BOARD OF HEALTH
..................................... I.... O F... ............................................. ................................
Trrtifiratr of Tomptian-6
THIS IS TP CERTIFY, That the Individual Sewage Disposal System constructed ( ) or Repaired 4__�r
- - -- ..........................................••............
--
Installer
has been installed in accordance with the provisions of TITLE 5 of -The State Sanitary Cqd as described in the
application for Disposal Works Construction Permit No...._f_:.... . _... .............. dated.....:r'..r�e .... L,' �...............
THE ISSUANCE OF THIS CERTIFICATE SHALL NOT BE CONSTRUED AS A GUARANTEE THAT THE
SYSTEM WILL FUNCTION SATISFACTORY.
DATE.........................::.................................---..... Inspector....---....--------......_•-----------................................