App-Permit-Compliance�i�3.:c.... - - •--- Fmc... 15.00...........
THE COMMONWEALTH OF MASSACHUSETTS
r
BOARD Off' HEAL
oF..........��1�/yicu.rid----------------------------------
Appliratiou for Disposal Works Cna nstrurtion ramit
Application is hereby made for a Permit to Construct (,k) or Repair ( ) an Individual Sewage Disposal
....stem at • / CerCW
5
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nBS .......
L
lz: Z Mi
ocaf�`°� Address or Lot No.
.....�i._Y..�7. f ..............................•...... ..................... ............................................................................
•----•...-----.... 1 .. ..... °��-'.� . 5 --•-----...---•--.........-
Installer Address
d Type of Building
Size Lot__�9__.L ----- feet
Dwelling —No. of Bedrooms............ Z...........................Expansion Attic ( ) Garbage Grinder04 ( )
'4 Other — T e of Building No. of persons ............................ Showers — Cafeteria
Q, Other fixtures -----------_----------- d ....................
�do
-••- --- ---
---------------
ZZ�Design Flow .......... /l_0.......................gallons per perk peday. Total daily flow -------------------------------------------- - -- --------------gallons.
WSeptic Tank —Liquid* capacity./000gallons Length5!V= 6..... Width.4.:/0_ Diameter ................ Depth --- ;:�_-�- -
x Disposal Trench — No ..................... Width .................... Total Length .................... Total leaching area .................... sq. ft.
Seepage Pit No ....... /-_____-_- Diameter._/lJ__ 5� Depth below inlet.__.EZ:-... Total leaching area ... Z�2..sq. ft.
Z Other Distribution box ( ) Dosing tank ) /
'~ Percolation Test Results Performed bY____ __ __1'!9 ................................................ Date ... Z ... ,1 _�_........
Test Pit No. 1... L._:?�._minutes per inch Depth of Test Pit .... 14_4... Depth to ground water ------ . .............
Test Pit No. 2................minutes per inch Depth of Test Pit. ................... Depth to ground water ........................
- S0
! ----- --------------------------
Description of Soil_._8...-di.....
••-----•-•••---•--••-•-------- ....•... ..... �M_E•�..... ...........................
------------------------------------- •----•---•--•---.-----
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 TIT1E 5 of the State Sanitary Code — The undersigned further a rees not to place the system in
operation until a Certificate of Compliance has been issued by the board of beakh.
Signed_....•...... --- ••-----•-•...-•-•---•------------------------ ----- -..... ....
D
Application Approved BY-�+ -----•--------•-•----------------------------------------...
ate
Application Disapproved for the following reasons:----•-•----------------------------------------•----------------
---------------------------------------------------•-----------------------.
Permit No ....... 4P -L-13 ------------------------------
...........................................................................
Date
P-L13------------------------------
.------------------------------------------------•-•----•------....-----•--
Date
Issued- --•--....��1 ,1. ........................
THE COMMONWEALTH OF MASSACHUSETTS
BOARD OF HEALTH
.................�7Gt1N .............. O F...... YA17C I7Tf I.........................................................
�ira~tifirtt#r of f�u�a�li�tnrr
ffEfSI$.,TO3 CERTIFY, That the Individual Sewage Disposal System constructed ) or Repaired ( )
Installer
at . TAT � _ ET[,E t ST-_�F,�r J)_'; t� ?CE� --`�---------------------------------------------------------------
--------------------
has been installed in accordance with the provisions of TITLE 5 of The State Sanitary Code as described in the
application for Disposal Works Construction Permit Noal-1.8.3 ----------------------------- dated ___.__1{�$/'81...........................
THE IS OF THIS CERTIFICATE SHALL NOT BE CONS UE® AS A GUARANTEE
THA THE
SYSTEM VILL.F.j�lInspector...._DATE.........•...... ..--•-TY
X14)