HomeMy WebLinkAboutApp-Permit-Compliancerca- �"//�//%Y'
No ... 7if - 4_ - FnB 1�..�1........ ' _
THE COMMONWEALTH OF MASSACHUSETTS
BOARD OF HEALTH
QW�Vl._..-•----...OF.......................................................
Appliration for Biipooal Works Tonotrnr#ion ramit
Application is hereby made for a Permit to Construct (fie) or Repair ( } an Individual Sewage Disposal
je System at: ACIP 5�
................................................. ClpT�! .....1' 1� r l o o ...:.f�.... ...__.
Location - Address or Lot No.
lop
Owner fi Address
-------------------------------------.......................................... -•---•--.._......._.............---•------....----....--•-•--•----------........................--
Installer Address
Type of Building Size Lot... --.-Sq. feet
Dwelling — No. of Bedrooms -----.----.CY-------------------------------Expansion Attic ( ) Garbage Grinder ( )
Other — Type of Building ............................ No. of persons ............................ Showers ( ) — Cafeteria ( )
Otherfixtures------------------•-----•--------------...------------.----•--•--•---•--•----------------- ...........................................................
Design Flow --------_-----------------►-. ......gallons per person per day. Total daily flow ....................... .. V -------- gallons.
Septic Tank — Liquid' capacity/bQ-4..gallons Length_ .0.. Width44! Diameter ................ Depth4. =_¢ `.'__.
Disposal Trench — No ..................... Width .................... Total Length........... �._..... Total leaching area .................... sq. ft.
Seepage Pit No -------- 1........... Diameter.& __+.Z!.. Depth below inlet ..... V......... Total leaching area..2_0*—.sq. ft.
Other Distribution box (k ) Dosing tank ( I ` 1479 g 7
Percolation Test Results Performed by.. ,..�__. L .%s�' .................. Date. l�:_.__.__...__._...._9
Test Pit No. lLE.[',P.2minutes per inch Depth of Test Pit.. f/4-6........ Depth to ground water..dY_O...........
Test Pit No. 2................minutes per inch Depth of Test Pit .................... Depth to ground water ......................
--------------------•-----....------......._-----------......------------------..__.._..---.....--•- ........................................................
Description of Soil ...... �.�L.L U....1-? EFOJ-O-41-...... S— sq. Mia ____QN06?� --- -o....., .Qf'f--.~./V-------
. ------•-----•----------•-------------•--•-•-•-........_..----------••-------•------•---•--•-•-•------•-------•-•---•--•-----•---•-•-------......---•----•-----------------
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 TITTIE 5 of the State Sanitary Code — The undersigned f ther agrees not to place the system in
operation until a Certificate of Compliance has been issue y e boa of 1 alth.
Signed .............. --- 1� ............................ ....
�" �s��.%t ...
Da4e
Application Approved By ..................... •-------------------------•--------------•--------•--.......---•-•----•----- .................... Da..............
Date
Application Disapproved for the following reasons: -•----------------------------------•-------•--------------.....-----------••--••---•-•---------------•••--•--•-
.....---•------------------------•-----------•-------------------------•--•------•--------------------•----------...-------- -------------------------------------------------------------------•---•---
Date
PermitNo --------------------------------------------------------- Issued ----------------------------
Date
THE COMMONWEALTH OF MASSACHUSETTS
BOARD OF HEALTH
.......................................... OF .....................................................................................
Tertifiratr of (fiontpliatta
THIS IS TO CERTIFY, That the Individual Sewage Disposal System constructed ( ) or Repaired ( )
---------------------•-•--•---------------- .....----------.----...
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 ................................................
THE ISSUANCE OF THIS CERTIFICATE SHALL NOT BE CONSTRUED AS A GUARANTEE THAT THE
SYSTEM WILL FUNCTION SATISFACTORY.
DATE................................................................................ Inspector.