HomeMy WebLinkAboutApp-Permit-Compliance. ... . .. .. ...........
No
THE COMMONWEALTH OF MASSACHUSETTS
BOARD OF HEALTH
OF.......
.. ...... ...................................
..........
for Difivatial Works Tomitrurtion Vamit
Application is hereby made for a Permit to Construct (4,<or Repair ( ) an Individual Sewage Disposal
System at:
----------------------------------
Location Address
Ow r
-----------------
........ .........
Installer
.............
or Lot No.
_Z .J..-- ...
Address
Address
Type of Building Size _Lo .... q. feet
Dwelling — No. of Bedrooms.----•-- �F ............................. Expansion Attic ( ) Garbage Grinder
Other—Type of Building ............................ No. of persons....._............_.__.._... Showers ( ) — Cafeteria
Otherfixtures -------_---_------ ........................................... ................................................................................
Design Flow ...... � 7 _
..........................gallons per person per day. Total da�y flow ------ 0*3 (V ..................... gallons.
Septic Tank — Liquid capacity gallons Length4�0.fr.. Width. _,/.. Diameter ................ Depth.6___/--'_*_'.
Disposal Trench — No - _---------- ------- Width.--............_.._. Total Length .......... --------- Total leaching area ..................... sq. ft.
f . .
Seepage Pit No ....... / ... _ .... Diameter./t2&
.-.0. Depth below inlet._'.�O.".-. Total leaching area ....... sq. ft.
Other Distribution box (/1_)0' Dosing tank ( )
Percolation Test Results Performed by ..... .Date... ... . .... -- -- -- ---
Test Pit No. 1_. ..minutes per inch Depth of Test ---- Depth to ground water.� -------
Test Pit No. 2 ................minutes per inch Depth of Test Pit.............._._:.. Depth to ground water................_._.__..
.... .........
.................................................... ............................................. ..................................
.... Y.r .. ...............................
Descri tion f Soil.. .0.
. 00"
............. ....... -e6F.Apl ....... ...... := ...... Inc.
. ................................................
.................... ...................................................... ............................................................................................................................
Nature of Repairs or Alterations — Answer when applicable ...............................................................................................
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 issued b the bo rd f health.
e
Signed...... .... ..r/ Z.7hr
. ... . . ...... . . .... . .................. .
Date
04
Application Approved By ...... ........ .................. ......... 5 . .... ;�_Zs
Date
Application Disapproved for the following reasons:-
....................
Date
PermitNo----------------------------------------------------•---- Issued-------------------------------------------------------- /
Date
THE COMMONWEALTH OF MASSACHUSETTS
BOARD OF HEALTH
.......................................... 0 F ...... ............................................................ ..........
(Intifiratr of Tomptiatta
THIS IS TO CERTIFY, That the Individual Sewage Disposal S7stem constructed (_' '�or Repaired
by........... ZZ-S--2.� ......... k_2�.�Lg2 .. .... ..............................................................................................................
Installer
at ....... 4e4 ';P ....... / Z
...............
w . .------- . .... . ....... .......................... . ..............................
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 ........... dated ................................................
THE ISSUANCE OF THIS CERTIFICATE SHALL NOT BE CONSTRUED AS A GUARANTEE THAT THE
SYSTEM WILL FUNCTION SATISFACTORY.
DATE................ cT. ----- jocW-.9f ---------------------------------- Inspector----------- -----.. ........ L2_1 ..... /