No preview available
HomeMy WebLinkAboutApp-Permit-ComplianceNo..%. .... .... Fps.......... �................. THE COMMONWEALTH OF MASSACHUSETTS BOARD OF HEALTH Q l R �..h ........... 0 F ........... 4.`"Y(.� ©j, ��..................................... Appliratinn for Disposal !Warks T. nstrurtion jhrmit Application is hereby made for a Permit to Construct ()G.) or Repair ( ) an Individual Sewage Disposal System at X l�(5- �-........� _uA "+ (o ,I ......... jUt-1L......---�.�e. � Location -Address --. or Lot N . ................................... ...... -- ...- -tom. —' 4>. ............. Addre --•-•----------------------- --- - ..... r .. 1.4 r Her Address Type of Building Size Lot.ZZ. 5 ! P.._.__.Sq. feet Dwelling `-7;"No. of Bedrooms ............................................ Expansion Attic ( ) Garbage Grinder ( ) Other — T e of Building ............................ No. of persons ............................ Showers — Cafeteria a Other fixtures ............................... . . W Design Flow ............................................ gallons per person per day. Total daily flow ............4 .................. gallons. WSeptic Tank —Liquid* capacity W.9P .gallons Length ................ Width ................ Diameter ................ Depth ................ x Disposal Trench — No ..................... Width .................... Total Length .................... Total leaching area ........... ......... sq. ft. Seepage Pit No..._....I .......... Diameter ... !.Zt5.-'.... Depth below inlet•....(a .. Total leaching area -16 $.! ..sq. ft. Z Other Distribution box X) Dosing tank ( ) Percolation Test Results Performed by .......................................................................... Date ........................................ Test Pit No. L ....minutes per inch Depth of Test Pit.... AV ._...__ Depth to ground water._ . Test Pit No. 2................minutes per inch Depth of Test Pit .................... Depth to ground water ........................ --------------------------•-------•--................•-•-•----......................................................... Descriptionof Soil -----L le -C. Yt..... 2r.?.is'l t--------------------------------------------••--.......-------------------•-----•----------... .-------------•------•--------.....----•------•-----------------........------------------------............... _..--••--.....-------------•-•-•......-•----------........-•••-----•-•--....--------•-•--- ---------------------------------------------------------------------------------------•------------ --------------------------------------------------------------............ •---------.....------•---- 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 TIT I.;,.. 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...................................................................................... ................................ Date ApplicationApproved By ........................ ................................... ............ .------ Date Application Disapproved for the following reasons: -----•--------------------•---•-------------•----------------••-------------....----------------------------- .----------------------------------------------------------------------------------------------------•....-•--•-------------••--------•---•--•---•••-••-••-•-•--••------••-•.----. Date PermitNo --------------------------------------------------------- Issued ....................................................... Date THE COMMONWEALTH OF MASSACHUSETTS BOARD OF HEALTH .......................................... OF ..................................................................................... Trr#ifirab of Tout lianrr THIS IS TO CERTIFY, That the Individual Sewage Disposal System constructed (>y1or Repaired ( ) by--------------------- '� .4, . -----------_ R has been ins. �---•-�=------------s-�---- �..---•--•-------ydlt! ....................................................................................... in accordance with the provisions of TTTLE 5 of The State Sanitary Cod as d �cribed in the application for Disposal Works Construction Permit No --- _--� �_____________ dated___. ` -�_ _�?_ __ _ .._._.......... THE ISSUANCE OF THIS CERTIFICATE SHALL PLOT BE C06dSTRUED ASA ARA TEH THAT THE SYSTEM WILL FUNCTION SATISFACTORY. DATE................................................................................ Inspector