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App-Permit-Compliance
(. � •rim -i., _ _ _ No.. ....�1- THE COMMONWEALTH OF MASSACHUSETTS BOARD OF HEALTH '.._/...C.�...W..._OF ...... .........-------- ---------- for --..--.-•---- for axk C o r t �t rx ti Application is hereby made for a Permit to Construct fe) or Repair ( ) an Individual Sewage Disposal System at: J ................__... :.... Y !! ��� - f ►.? ?`��- lf-•------�----- Loc on . Addr ss o- Owner 1 Address w .� • C ._e_. - _E1 .l d -`%�'� ... ......_ f}l.r�-t�_U7 1' T ---------•------------ a Installer Address QType of Building Size Lot.lg.;;�©4�-------- Sq. feet ' Dwelling — No. of Bedrooms ................ ...................... Expansion Attic ( ) Garbage Grinder ( ) A4 Other — Type of Building ............................ No. of persons -------•-••.•___---.______-- Showers ( ) — Cafeteria ( ) Ga Other fixtures ------------------------------------------------ Design Flow ........... .......................gallons per person r day. Total daily flow ........... �� ................ gallons. W OLength._'?. r Septic Tank — Liquld capacity.._..'.gallons Length_____ ________ Wldth___._�_._._. Diameter______.._____.__ llepth___..___.___.__. Disposal Trench — No- ----------------•_-. Width .................... Total Length ..........._. T... Total leaching area ----------- --------- sq. ft. Seepage Pit No ....... /........... Diameter ...... 0....... Depth below inlet... t.r3 -_- Total leaching area_ ----- sq. ft. Other Distribution box Dosing tank ( ) '-' Percolation Test Results Performed by._ D, '@. ........ ..... Date -•_-�_:_ `�'_• ...... Test Pit No. 1 .....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 ........................ ................................ --.....................................................------------------•----.._..--------.....------------•-- Description of Soil Q..... $4' -- - -•--- U •--•-----------•-- •---•- --......'e �..-, . W----------------------------------------------------------------------------------------------------------------------------------------------------------------------------------- .................. U 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 i ITL.E 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 Application Approved By ..... -----•----•- . ...A -a .•.. � yam- -- ------ � / Date Application Disapproved for the following reasons----------------------------------------------------------------------------------------------------------------- Date PermitNo--------------------------------------------•--------•--- Issued ------------------ --------------••-------------•------- Date THE COMMONWEALTH OF MASSACHUSETTS BOARD OF HEALTH .......................................... OF .......................... 11 ......................................................... x �ir����rtt� of f1�la�tt��i��tr�e THIS IST �ER/TIFY, Thai tkle Individual Sewage Disposal System constructed (.)<) or Repaired ( ) b % `! .....................................-----•......---........ y------------------- instaii at. 1 has been installed in accordance with the rovisions of TITLI'; 5 of The -fate Sanitary Code s described in the application for Disposal Works Construction Permit No.___'J_—s dated___._- .,,� �?_ __7 THE ISSUANCE OF THIS CERTIFICATE SHAL NOT BE CONSTRUED AS A G ARA EE THAT THE SYSTEM WILL FUNCTION SATISFACTORY. DATE................................................................................ Inspector.