HomeMy WebLinkAboutApp-Permit-Compliancei
No.g 3S7 Fim.... ... _. s -
THE COMMONWEALTH OF MASSACHUSETTS
BOARD OF HEALTH
.................. ................OF ........................................
......
Appliration for Disposal Works Tonstrartion rrrntit
Application is hereby ma# for a Permit to Construct ( ) or Repair ( V an Individual Sewage Disposal
Systean at
................•-•--•--•--_..-..-__--•--•A.n.-
-- - --- --- --
on- ress ! , O or Lot o.
O er A r ss '-
s...............................> .. F... r ....... ... .....
Installer Address
� feet Type of Building Size Lot__________________________ _ S q.
aDwelling —No. of Bedrooms .................. �,l____________________._Expansion Attic ( ) Garbage Grinder ( )
p,,, Other — Type of Building ____________________________ No. of persons ............................ Showers ( ) — Cafeteria ( )
04 Other fixtures ..........................................
W Design Flow.............lj 0.___.._________________._gallons per person per day. Total daily flow ............................................ gallons.
WSeptic Tank — Liquid ca.pacityok V_gallons Length ................ Width ................ Diameter ................ Depth ................
x Disposal Trench — No . .................... Width _f_.__.___________._ Total Length ---------
I--------- Total leaching area .................... sq. ft.
3 Seepage Pit No.____.�-----------Diameter ___6_____________ Depth below inlet_�j____.._.._..__. Total leaching area .................. sq. ft.
Z Other Distribution box V_ Dosing tank ( )
a 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 ........................
DDescription of Soil ... ---•-- --------••--------------------------------------------------------------------•---..__...._•---•------
W_______________________________________________________________________________________________________________ _____________ �.— __. T r
j —
V Nature o R airs or 4lterati s —Answer w ppl' le._ _
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 furtl: grees not to place th system in
operation until a Certificate of Compliance has been,issugo by the bo�i-d� healt
Signed_
Application Approved By____
Application Disapproved for the f oll
Permit No--------------------------------
rY-� ----
-- -------------------------b/.. k
-•-Date
Issued
Date
THE COMMONWEALTH OF MASSACHUSETTS
BOARD OF HEALTH
.........................OF.....yf) G? (!�.�i..% .........._...
Trrtifiratr of Tontpfiatur
THIS IS TO CERTIFY, That the Individual Sewage Disposal System constructed ( ) or Repaired (` )
b
Installer
at....- ---- t ..................................-- -- `------------------•-----------•----- -----•--•-----------------------------------•-------------------------•--------•-----•---------
has been installed in accordance with the provisions of TITLE 5 of The State Sanitary Code as described in the
application for Disposal Works Construction Permit No r.:c ------------------- dated -._. __
THE ISSUANCE OF THIS CERTIFICATE SHALL NOT BE CONSTRUED AS A GUARANTEE THAT THE
SYSTEM WILL FUNCTION SATISFACTORY.
LL
0
0
m
G
VP4
�f
U
U
0
P4
c�
0
b
.4
a
O
0
,a
_ cbdA y
V) y .
b
ro
A
O
: A
bb
0�
f•n
c a
3
^
CCd
3
IV
` 4' `.
"a
buO
?x
0 o
bA
Tj
�V)�.�
O O
a�
o
o b4
U
=
`
o
a
O
041
WD
as
o
0
hoVO
Cal
Q,
a� v
iE�Ei
-o
oa
o
'z
W
O
co
q q
J
W
as �
A
0
o
41
0
-R "d :q
y i
�•
a
O
O ,N N
r
to
�. Cd
a' a
Y
I a
a v
H
..
V i cd �.
•
s~ a'
� v
En .b
W
O
:b
'
0
00
z�
000
a o
txo
r. I HO
z'�
�zz
'b he I
a0i .0
H41
PL.,
.0
SAO.
a 4En
i
En 0
O
0
,a
'a'MVOI'IddV a2I[HM NII 'I"II3 ?IO NO=
ro
A
z
N
Fes•'
W
N
x
U
N
N
Q
LL
0
x
J
Q
w
Z
0
0
U
W
x
F.
f.'
Q
W
2
W
0
O
m
..
N
a
w
0
O
1
cd
C
.1
aa,
U �
� v Q
Ctcd
b a
dUl
Ce
Z
o
LU
L to
i� Z
H : J
i H o J
'n N
'0 ani 6W— �
0 0 00
CL LL
1
WV)
V F-
3 O Q
a U 4
�x z
0
LLO
O✓ OE..
cce , W z
v� z t'1.
Q Hj
n w N
� 0
W
ami i— fW„
c�0 .c cdd y
O
a
0
W
ro
A
: A
0�
N
F -
w
) o
� 0
a�
o b4
U
=
o
a
6 o
Cd
�b
0
hoVO
0
E W
-o
A
o
W
O
co
t
J
W
D
A
0
5
? V)
41
0
41
0
O
..n
i
I a
•a
a
� v
En .b
Cd
ani q)
o
3Ck;
.n
Oall
0
0 0
cd cd
En cn a
�
r i
N 0
Z
U
O
+�
14
0
M00
u, 0
'
d
S.
4'�'
V
^
ca
�\
E U
W
to o `d
S.
04
ta,
In
0
0
0
0
`
a O
a
Z
°
a
d
u
004
�a
'a'MVOI'IddV a2I[HM NII 'I"II3 ?IO NO=
ro
A
z
N
Fes•'
W
N
x
U
N
N
Q
LL
0
x
J
Q
w
Z
0
0
U
W
x
F.
f.'
Q
W
2
W
0
O
m
..
N
a
w
0
O
1
cd
C
.1
aa,
U �
� v Q
Ctcd
b a
dUl
Ce
Z
o
LU
L to
i� Z
H : J
i H o J
'n N
'0 ani 6W— �
0 0 00
CL LL
1
WV)
V F-
3 O Q
a U 4
�x z
0
LLO
O✓ OE..
cce , W z
v� z t'1.
Q Hj
n w N
� 0
W
ami i— fW„
c�0 .c cdd y
O
a
0
W
;A
ix
7MT
p
ro
A
N
F -
w
U
=
o
0
A
o
W
O
co
O
J
W
D
5
? V)
41
0
0
O
i
m
?
°
w
o
0
q
o
O
^
ca
`
a O
O o
0
u
z
40,4
;A
ix
7MT
p