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App-Permit-Compliance
a V P4 No....©..._. Fzaa...... THE COMMONWEALTH OF MASSACHUSETTS BOARD OF HEALTH ..............< ..( 1..t�1......... OF.....�/.W.f4-NfY% ........................................... Appliratiun for Disposal Works Tonstmtion Frrmi# Application is hereby made for a Permit to Construct ( ) or Repair C\.. -,ran Individual Sewage Disposal System at: ....._......__ ._..�. ........................... -~ Location - Address k ........................... Owner -Installer or Lot No. MAP 5 i D �[ Address ........... 1 •l .�Lt...k�? 4 .-_' L�............................................ Address Type of Building Size Lot ............................ Sq. feet Dwelling— No. of Bedrooms ...��.....................................Expansion Attic ( ) Garbage Grinder ( ) Other — Type of Building ............................ No. of persons............................ Showers ( ) — Cafeteria ( ) Otherfixtures.--•---------•---•------------------------------------.•----•-----•-----------•--•----•-•-------•---•-----...•....---........------•--.........------- Design Flow ....... 5:> .........................gallons per persongr day. Total daily flow......... : 5.'_3 �6..............__......gallons. Septic Tank 4- Liquid' capacity tC.0'1J_gallons Length............. Width.... ......._ Diameter ................ Depth ................ Disposal Trench — No ..................... Width .................... Total Length .................... Total leaching area -------------------- sq. ft. P Seepage Pit No ------ /............. Diameter .... l.2�......... Depth below inlet .... L............ Total leaching area .................. sq. ft. Other Distribution box ( ) Dosing tank ( ) Percolation Test Results Performed by--•-•---•-------•--------------•--••-------•-----....-----•-•-----•-_.... 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........................ ----------------------------------------------------------------------------- Descriptionof Soil ........................................................................................ ------------------------------------•--------------.._......------------------------------------------------------------------ -----------------------------------...------------------------------...-- Nature of Repairs or Alterations — Answer when applicable .... �- M."T .0 k t-----. ------. ------..0- _8a ............ .... L_'A k---ZmaN�----------•------------------------------------------------ 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 issued by the board of health. Signed....- ......ter.:� )."1.b'... . D t ApplicationApproved By ............... . --....... •--•----•---•-----•------------------------------•-•----------- e �r to Application Disapproved for the following easons:.............................................................................................................. ....-----•--•---------•----------------•---------........--------------------.........---.----------------...----------------...............-----------------------•--•----•----......... q ate PermitNo ...... --•-•----------------------•------------- Issued. ........... JD`s-..1--......---......... THE COMMONWEALTH OF MASSACHUSETTS BOARD OF HEALTH ��C71tY............. OF ........ .t4!!l.t1 Sa .............................. (Inr#ifira tle of Tomplinnrr THIS IS TO CERTIFY, That the Individual Sewage Disposal- System constructed ( ) or Repaired ( by.................................... 4- Y.04 - .._._. - - - ._ f� n Installer Vn at ---------------------6- =2-1 ....... ---- .�-� .._..1`t�C2Q t`'::%..----------------- ..................... ........................... has been installed in accordance with the provisions of TITo_f The State Sanitary Code as escribed in the application for Disposal Works Construction Permit No .... _C__J_�_6'".!G___________________ dated ------ ._ _.�..�.�...._................. THE ISSUANCE OF THIS CERTIFICATE SHALL NOT BE CONST ED AS A GU RANTEE THAT THE SYSTEM NILL FUNCTIO SATISFACTORY. DATE.... ...:. ......................... Inspector.. - .4N.... --------- ................ ---