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9 N — FEB 60 ............. .
THE COMMONWEALTH OF MASSACHUSETTS
BOARD F H
1_. .................... OF..-_. ...... ............... _........... ....... ........................................
Appliration for Dispos, Works on#.rnr#ion rami#
ti Application is hereby, e for a Permit to Construct (,) or Repair ( ) an Individual Sewage Disposal
Sys�. -•............................................................... �.. ..-•-
Loc tion - - d ss or Lot No.
Owner ----------------- -•••--_aares........_..._..._......................._.
A� ....--.................................... ....._....... -- �.....
Installer Address
Type of Building Size Lot. •j.d,J..._____Sq. fe t
V Dwelling — No. of BedroomQ-
P.,
.....................................Expansion Attic ( ) Garbage Grinder )
Other—Type of Building _---------- _....... No. of persons ............................ Showers ( ) — Cafeteria ( )
Other fixt re& ----•------------•------------•-----•-----••-•------------•••----------•-----•--••-------•---------- ------------------------------
------A --•----------------•---------
Design Flow..............a:...._........._.__ gallons per perso�er y. Total ily ow______---------------------- Ions.
P4 Septic Tank —Liquid* ca.pacitygallons Length.4?'_ �. Width`r_. Diameter________________ Depth-___�,�___..._._
Disposal Trench — No. .................... Wid --------------
Total Length .............. Total leaching area ___.._._..___..__ _sq. ft.
Seepage Pit No._l�__!1±+�___ meter___ __ _________ De th below inlet,.t�r-$..._._. Total leaching area.4fi_4_ :.sq. ft.
Z Other Distribution box"( Dosing t ( �4.
`'' Test Results Performed b ------ ........................... Date___._ ...Percolation Te yy Y�� - .. �/_..--•--.
Test Pit No. 1_..._._.Le�._minutes per inch Depth of Test Pit../.k::!...____ Depth to ground water_____________________: _.
Test Pit No. 2................minutes per inch Depth of Test Pit .................... Depth to ground water ........................
R6y •---•---------••-------•-----••-•------•----•-----••--•-•---...•-•-----•••---------------•--------------•---•---••-••----•------••-----•-•----------------
0 Description of Soil ........................................................................................................................................................................
U ,_-__---•-•----•--------------------------------------------------------------------
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W...•--------•---•--------------•-...-------•--...------•--•-•-•-•---------------------------•-••-------------------•---------•-----••-•--------------•-•---------•----•-••---- .........................
UNature 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 TITLE 5 of the State Sanitary Code — The undersigned further agrees not to place the system in
operation until a Certificate of Compliance has been i d by the board of health.
C1 la
Application Approved B}c�!��%�_�l..... .. --- -.._
Date
Application Disapproved for the following r ons--------------------------•------•-------•-------•--•-------...-----------------------------••--------------_....
... ....---•-•-•---•------•----------q-----•—---•--•-•----•-----•-----•----•------•---• •-•---------•---•..--•----•-------•----•------• • •-----•-------------• •----...-•---U----.... --Date-- •-------•---
Permit No._S��_..e_)r-_�0-......................... _.... Issue 12. ...-te ---
by
THE COMMONWEALTH OF MASSACHUSETTS
BOARD ¢F HEALTH/
................
f ntifir4 u/ of f9ontlili�tnrr
IS IS__ZO CERTIFY, That the Individual/Sewage Disposal System constructed (� or Repaired ( )
Installer
has been installed in accordance with the provisions of TITLE 5 of The State Sanitary Coe # described in the
application for Disposal Works Construction Permit No.$6- 5 -------------------- dated_ } o /jj -_----••-------•---•-------
THE ISSUANCE OF THIS CERTIFICATE SHALL NOT BE CONSTRUED AS ARANTEE THAT THE
SYSTE IWILL UNCTION SATISFACTORY.
�ya.
DATE ....44--1)J1571 14 Inspecto ---------------------- .................................