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No._ - 7-� F� .....7.7..:....x 4
THE COMMONWEALTH OF MASSACHUSETTS
BOARD OF HEALTH
0.1 ...... OF ........ .. e_-1771----------•----••---------------------
Appliration for Dispaoul Works Towitrurfian Famit
Application is hereby made for a Permit to Construct
or Repair ( ) an Individual
Sewage Disposal
System at:
_ ......
Location -Address
�o J.......................................-"--".........
or Lot No.
..................................................
W `' .....__
OwnerAddress
.�-......�............................................
� ` [__� ......
_► ,
mInstaller
Address
Type of Building -3 Size Lot ... _.-�Za2....... Sq. feet
Dwelling —No. of Bedrooms............................................Expansion Attic ( ) Garbage Grinder ( )
Other — Type of Building ............................ No. of persons ............................ Showers ( ) — Cafeteria ( )
Otherfixtures -----------------------------------------------------------------------------------------------------------------_------------------------------------
Design Flow ............... --------------------gallons per person per ay. Total daily flow ............... ..�3_ v...._._.__...._..gallons.
-Septic Tank—Liquid capacity.f4ao.gallons Length.__�.`�.' ". _ Width...'41Kk_ Diameter________________ Depth..S�'_"
Disposal Trench — No . .................... Width .............. ._.... Total Length ..................... Total leaching area... ................. sq. ft.
Seepage Pit No --------- ---------- Diameter....... ... Depth below inlet.... . Total leaching area.3qZ_?.sq. ft.
Other Distribution box ( ) Dosing tank ( )
Percolation Test Results Performed by .... 47�/2;P.._......4 ........ _ ___________ Date..'S w -a -
Test Pit No. 1 ... G¢ ---- minutes per inch Depth of Test Pit ---- So .-_
_ Depth to ground ater-------- ...............
Test Pit No. 2--- _---minutes per inch Depth of Test Pit. -..1/ ...... Depth to ground water ..... ______
r-+ ---------------- ._.
'.._._..----_..___..._.___.---_.__..__.__..._.._.__....._........................ .........................................................
D Description of Soil------- 6 e�� ca " W&04. ►?`?....u8 eSo�� >r— v t� - _ �i�l --------------------
W------------------------------------------------ •......................................................... -----------------------------•-------------------- ----------------------------------------
VNature of Repairs or Alterations — Answer when applicable ----------------------------------------- ......................................................
Agreement:
The undersigned agrees to install the aforedescribed
the provisions of ITLE 5 of the State Sanitary Code —'
operation until a Certificate of Compliance has been'vsuh
Application Approved By
Individual Sewage Disposal System in accordance with
he undersigned further agrees not to place the system in
V the and of health.
Date
------- ... 1 �.-.------.. ......--
Date
Application Disapproved for the following reasons_________________________________________________________________________________________________________
----------------------------------------------------------------------•--• ------------...._..••--•----'•-----------•---------•------•------------------------------------------------••--------
-�
q ----- Date
------
Permit No.__... ..1 --------------------- Issued_.-- ---_.`_. -�----
Date
THE COMMONWEALTH OF MASSACHUSETTS
BOARD OF HEALTH
..................�t.�!!r^/......\ 21-;; J LI -7-71-
./T ... o F ........................
Tntifiratr of (Inntpliatta
THI�,TO CERTIFY, That the Individual Sewage Disposal System constructed (t.,I`or Repaired ( )
Installer
•----------------------- ----------•......------• ...
has been installed in accordance with the provisions of TITiE 5 of Th State Sanitary Code as described in the
application for Disposal Works Construction Permit No.__._ y5�1_ _ �� ` �
------• dated._...._/.f
THE ISSUANCE OF THIS CERTIFICATE SHALL NOT BE CONSTRUE® AS A GUARANTEE THAT THE
SYSTEM WILL FUp�ICTION SATISFACTORY. �----
i� lam. �- >{_ �_ G1 KI 1@ c s .ti�•
DATE...---.....-'---------------------)----------'---------•---- Inspector....---•--------------------------------------•--------•-------------'--'-"'-'•--.
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