HomeMy WebLinkAboutApp-Permit-ComplianceTHE COMMONWEALTH OF MASSACHUSETTS
BOARD OF HEALTH
1. - %1............... OF...... !N t
Appliration for Disposal Works Tontrnr tan frrmff
Application is hereby made for a Permit to Construct (X,) or Repair ( ) an Individual Sewage Disposal
t� System at,
........ _ o .....
Location -Address
o.
Owner Address
............................ .......------•----......--•------•--.......---
Installer Address
Type of Building Size Lot ---r ......Sq. feet
Dwelling —No. of Bedrooms ........... J ............................ Expansion Attic ( ) Garbage Grinder ( )
Other —Type of Building ............................ No. of persons ............................ Showers ( ) — Cafeteria ( )
Other fixtures-----------••-----------•--------------------------•--.
Design Flow ........... ...... _....................... gallons per person per day. Total daily flow._ �0k_ __ _'�t ..... gallons.
r -
Septic Tank —Liquid capacity_ gallons Length_ �? :�� �_. Width___._.'_ �Q_. Diameter________________ Depth_
Disposal Trench — No..................... Width .................... Total Length .................... Total leaching area__________ ._.__.__.sq. ft.
Seepage Pit No ....... 9 ............. Diameter ...... �'zc'....... Depth below inlet --- Total leaching area..`-`�_____sq. ft.
Other Distribution box k) Dosing tank ( )
Percolation Test Results Performed b ._....4__ _ v.• �iAc�-. ___...'ems ........... i� - :`_�'' _---_-__-.
Y > •---•-. Date
Test Pit No. 1__ C.:_ minutes per inch Depth of Test Pit ----- ....... Depth to ground water ..�l-�� �.A C .......
Test Pit No. 2................minutes per inch Depth of Test Pit .................... Depth to ground
-----•-----------------------------•-•--------•-------------- .....� _
Description of Soil -------•---------------•----- ............................................ 6" 6 `1 2 �................. --.--
---------------- ---------------- -------------------------------------------------------------•--•--------
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 TITILj 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 by the board of health.
Signed. Illi'�------------------------------•-------------------7. J ----•-
Date
ApplicationApproved By ..................................................................................................
Date
Application Disapproved for the following reasons- ---------------•---------------•-------------------•---•------------------------•----------•---•----------------
Date
Permit No ........ $r, r�--------------------------- Issued.---Z.1Z.1 .Z.C�i........................
Date
THE COMMONWEALTH OF MASSACHUSETTS
BOARD OF HEALTH
.......................................... OF .....................................................................................
Trrtifiratr of Tontpliatta
THIS IS TO CERTIFY, That the Individual Sewage Disposal System constructed ( ) or Repaired ( )
by----------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------
Installer
at. ............................
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..... . _`_>___ _.`-=------------------ dated-__.__ r'_ L;? _ . ' __......__................
THE ISSUANCE OF THIS CERTIFICATE SHALL NOT BE CONSTRUED AS A GUARANTEE THAT THE
SYSTEM WILL �
F NOTION SATISFACTORY.
�< <�
DATE ....... Inspector t. .�^^-� ��1� k
...........................