App-Permit-ComplianceNo.. .................
THE COMMONWEALTH OF MASSACHUSETTS
AR® QF HEALTH
....... OF........ ...................-------•---------------------•-------............_
Appliration for Disposal Works Tow34rnrtion vrrmit
Application is hereby made for a Permit to Construct ( ) or Repair 4 an Individual Sewage Disposal
System at: {Je1n1 A e�5: 83 cam, D+RC2otc.>
..- X15 . -� .•---. •---.-----.-••.................••-----------.-----------...-----.._............_.
.. _... ..
ion - Ad mess or Lot No.
............. .. ------.. -- . . .... --........
....... •---
Owner y_Address...
Installer 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 -------------------------------------------- gallons per person per day. Total daily flow -------------------------------------------- gallons.
Septic Tank —Liquid capacity ............ gallons Length -----------_-- Width ................ Diameter ... _------------ Depth ................
Disposal Trench —No - _._-_---•-_-•--• Width .................... Total Length .................... Total leaching area .................... sq. ft.
Seepage Pit No --------------------- Diameter .................... Depth below inlet ..... _.............. Total leaching area .................. sq. ft.
Other Distribution box ( ) Dosing tank ( )
Percolation Test Results Performed by .......................................................................... Date ........................................
Test Pit No. I................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.
--------------------------------•----------------------------------------------......--------------•------------------------------------- ..........................................................
Agreement:
The undersigned agrees to install the aforedescribed Individual Sewage Disposal System in accordance with
the provisions of TITT.I 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- -- •--•--•----- --1 ..I.ca .iZ2 -�
lipal th O f icer Date
Application Disapproved for the following reasons--------------------------------------------------------------------------------------------- _------•---------
Date
PermitNo --------------------------------------------------------- Issued ---------------------------------------- ---------••---
Date
THE COMMONWEALTH OF MASSACHUSETTS
BOARD OF HEALTH
............14 .I.j.f.L✓......... OF ..............I...................................................
Tnriifiratr of ToutptiFanrr
THJS4 TOC RTIFY, Th heIndivi al Sewage Disposal System constructed ( ) or Repaired (�
y = -- --------
b
� Install
,�yy / .
at----- i -----------•
has been installed in accordance with the provisions of TITLP, r The State Sanitary Cods described
application for Disposal Works Construction Permit No ------ __._--_•. dated___________
THE ISSUANCE OF THIS CERTIFICATE SHALk NOT BE CONSTRUED AS A GUARANTEE THAT THE
SYSTEM WILL FUNCTION SATISFACTORY.
DATE..................•---------•-••---------...------.............----------•-.---- Inspector