HomeMy WebLinkAboutApp-Permit-ComplianceI
y4
THE COMMONWEALTH OF MASSACHUSETTS
BOARD OF HEALTH
Appliration for Dispau tl Works Tonstrnrtion Vamit
d
U
a
a
W
w
x
w
U
Application is hereby made for a Permit to Construct ( ) or Repair (
) an Individual Sewage Disposal
syste�m� at:
�....
r, Location - Add ,, or
r' ......r,v /� t o.
Owner
------------------------------
Address
Installer
Type of Building
Address
Size Lot ..... _d. ... Sq. feet
Dwelling — No. of Bedrooms ............................................ Expansion Attic (
) Garbage Grinder ( )
Other — Type of Building ............................ No. of persons ............................
Showers ( ) — Cafeteria ( )
Other fixtures -------------------------------- -- ---------------------------------------------
Design Flow ..................... IZd............. gallons per+e"on per day. Total daily
----------......--•--•----------
flow ............. ---•-................... gallons.
Septic Tank —Liquid capacityZ5�6Qgallons Length B I_.�. _. Width.. __ . Diameter..._..•._-_..... Depth...
Disposal Trench — No ..................... Width .................... Total Length ....................
Total leaching area ...........---------sq. ft.
d
Seepage Pit No...____f.._._.__.. Diameter ........ Depth below inlet ___._�....._____.
Total leaching area__..Z... sq. ft.
Other Distribution box ( ) Dosing tank
Percolation Test Results Performed by .... ..../1. !
�ate.... 1. ........
Test Pit No. Le,"' ;Z..::..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 ........................
•--•-----------------------------------------------
P"-- ' . Tom �Su/a��/c
Description of Soil ..... .................�..---------------•-•-----------'��-�-----
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 TITIE 5 of the State Sanitary Code — The undersigned further agrees not to place the system in
operation until a Certificate of Compliance has be, I e by t board of health.
igned !------•----•------------------------•---------- ...... .-------21
---
Application Approved By..... _
Date
Application Disapproved for the f ollowi reasons: --------------------------------------------------------------------------------------------------
-
�� Date
PermitNo ......................................................... Issued --•---• - t _
Date
THE COMMONWEALTH OF MASSACHUSETTS
BOARD OF HEALTH 17Y -,N
...............................� ..... OF. . -.
................... .
�
rrtif' atr of Toutpliatta
THIS IS TO CERTIFY, That the Individual Sewage Disposal System constructed ( ) or Repaired ( )
Installer
at......................................... , ----.........-t =' ` ---•-----------------------------
-----•------------•------•----------------------------------------------------
has been installed in accordance with the provisions of TIT LF 5 of The State Sanitary Code as described in the
application for Disposal Works Construction Permit N• ...... _.. K-.7 ... ............... ...... date r ----.----------------
THE ISSUANCE OF THIS CERTIFICATE SHALL NOT BE CONSTRUE® AS QUARAIT THAT THE
SYSTEM WILL %%FUNCTION SATISFACTORY. /f
DATE.............?,l .: } �..�....__....................--•---•---•-•-- Inspectorrz -'--•-