HomeMy WebLinkAboutApp-Permit-Complianceed- 322- .... ..60.No....
THE COMMONWEALTH OF MASSACHUSETTS
BOARD OF HEALTH
.. ...............................OF......................... ------..I....---- ----- -...............................
Appliratinn for Dhipoiittl Works Tomitrnlr#inn ramit
Application is hereby made for a Permit to Construct
( ) or Repair (X) an Individual Sewage Disposal
?-q-
Type
y
......F. ...............................
Installer
-----------------------------------
Address
.............................................
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 ........................
------------------------------•---------•-•-------••---•---•---•-•-•---------------------....................--•----•---...---•----•'-------••---.......... _.
Descriptionof Soil-.......................................................................................................................................................................
--------------------------------------------------------_----------------------------------------------------------- -------•--------•-
R
Nature of Repairs or Alterations Answer when applicable.______/d�_.___._..._...L___________________________________
----------------------------------------------------------•------------------------•----------•-•------------------------------..... l __.--------------------------------------------•---------------
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 Compliance has been isse by the board of health
Signed. ----- �--- . .....�..-- --...............
Application Approved BY � ------I -- -------•--------------------------•-----•------------_-------------- 1i n +�
to
----
Date
Application Disapproved for the f ollo ang reasons----------------•----------------------------------------------•-------------------------------------------------
---------•-----------•---------------------------•--------------------------------------------------•-----•------------•---•---•-•----•'--••---'--•'-------••-----'•---•-'----------•• ................
Date
PermitNo ......................................................... Issued_ .......................................................
Date
THE COMMONWEALTH OF MASSACHUSETTS
BOARD OF HEALTH
.......................................... OF ................................ ............................. ..................
Trrtifiratr of Tontlilittnrr
THIS IS TO CEVJIFY, That the Individual Sewage Disposal System constructed ( ) or Repaired (K )
bY----------------- ' JY --......................................... ..,.:------------------------------------------------------------------
Install r //
at------•---•-----'•--•----•----...... `1•------------ . = :1-i_= I/Z... `� = ---- --------------------
-------------- -
has been installed in accordance with the ro isions of TITLy� r of The S ate Sanitary nde as desc ib d in the
application for Disposal Works Construction Permit No.___..�–�_.2 dated_-..._1�;�__ ___.._...__.
THE ISSUANCE OF THIS CERTIFICATE SHALL NOT BE CONSTRUED A$jA GUARAN EE THAT THE
SYSTEM WILL FUNCTION SATISFACTORY. '
rl n mr.