HomeMy WebLinkAboutApp-Permit-ComplianceTHE COMMONWEALTH OF MASSACHUSETTS
BOARD OF HEALTH
..........................................O F...........................-................-..-.-..•-
Appliration for Disposal Works Tonutriirtion jrrniit
Application is hereby made for a Permit to Construct ( ) or Repair ( ) an Individual Sewage Disposal
System at:
Location - Address
................. Vin�: S ..._. S.? _sG__K :`C...--•--`-••---.._...----•----•--------•-
f.---------`- ^ L? .. a E! ..---------
Installer
...._.. ....�. (_ t U --------- •-------------- •...........
-----
or Lot No.
--:2!!! 6...........................................................
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 ' capacityl_P?v_gallons Length ---------------- Width____.;_____.._.. Diameter______....______ Depth ................
Disposal Trench — No . .................... Width .................... Total Length .................... Total leaching area .................... sq. ft.
Seepage Pit No .......... j-ZoODiameter....___ls?......... Depth below inlet.__.: 2 1 __.. 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...................................•----•-----------•---•-------••-•-----••--•....._._
....................................................... --..----------------------•---------•----••••---••••-••------•--_._.._..-•••-...-•••---•--.....................................................
Nature of Repairs or Alterations — Answer when applicable ....... L5cX:::2..... ........ D__._..&o.K.........
(a a............ ._.F... S `.o v�................................................ •----------------- •--------
........
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 hasjiecn issued b -?the boa of Ilea .
Application Approved By__ _. ..__�
Application Disapproved for the following reasons:..
Permit No ........ �
-3Uate -9E ,Z
---------•---_......
Date
Date
Issued-..._.._........................ 2 1.--•-- ......
Date
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THE COMMONWEALTH OF MASSACHUSETTS
BOARD OF HEALTH
. .....................................
(Intifirair of faomplinurr
THIS IS TO CERTIFY, That the Individual Sewage Disposal System constructed ( ) or Repaired ( )
Installer
at........ =fit- =-- ....== '=y '=— ✓` ==' =---- - =Z -
'-
has been installed in accordance with the provisions of TITh 5 of The State Sanitary Code as described in the
application for Disposal Works Construction Permit No ---- _.__r :-3 ............. dated _... �`__::. �?,:1_:_.�.=!_____._.__.....
THE ISSUANCE OF THIS CERTIFICATE SHALL NOT BE CONSTRUED AS A GUARANTEE THAT THE
SYSTEMA WILL FUNCTION SATISFACTORY. ,
DATE.....------� - . j. ° ............................... Inspector �._r.... -.