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THE COMMONWEALTH OF MASSACHUSETTS
�,— BOARD OF HEALTH
l..Qt ly'►.......................OF C.vara.? P(C11h.....:::.-•---------------...----------•-.....------....-----
Appliratiutt for Disposal Works Tuttu#.rudiuu Errant
Application is hereby made for a Permit to Construct ( ) or Repair (*) an Individual Sewage Disposal
System at:
.... aN .r.. Sc?w�ii. Lwr�2� � 07 f�ZO
,rci---•---•-------• ................... ............. - ----.....----------------------......--------.--
Location - Add�ss or, Lot No.
.....l oR� rP.sic:�sc:.--•------------------------------------------------------ -fuo_. nt�sr-��asu.�,..L. lles��R, ��.....�..20..........
Owner Address / /�
W (� 350 l�%ltea n.5-�...�.s-l1ct Rl�lc�if4---•...............
pq Installer Address
6 Type of Building Size Lot ................ Sq. feet
U Dwelling —No. of Bedrooms .................... .................... Expansion Attic ( ) Garbage Grinder ( )
Other — T e of Building ............... No. of persons._.._................_...... Showers — Cafeteria
a Other fixtures --------•----------•---------•----------------
W Design Flow ............................................ gallons per person per day. Total daily flow ............................................ gallons.
WSeptic Tank — Liquid capacity ------------ gallons Length ................ Width ................ Diameter ................ Depth ................
x Disposal Trench — No ..................... Width .................... Total Length.................... Total leaching area .................... sq. ft.
Seepage Pit No ---_--------------- Diameter .................... Depth below inlet..--................ Total leaching area .................. sq. ft.
Z Other Distribution box ( ) Dosing tank ( )
Percolation Test Results Performed by .......................................................................... Date ........................................
,`-4a Test Pit No. l................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
-----------------------------------
--------------------------- Cr.�..11................
Nature of Repairs or Alterations —Answer when aPPlivable_.!tzA4sf�..... ?.l_C�.n1..........
mr r =-----------------------------------•--•----...-•---------------•--------------------------------....---•----------........----•-----•------•................----------
AgreemeiYt :
The undersigned agrees to install the aforedescribed Individual Sewage Disposal System in accordance with
the provisions of TI 'L 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.
Application Approved By...........
Application Disapproved for the f ollowinglye' asons:..
Permit No.....:j���.... �'
------------- --_--
................... -.....
j�............................- / Date .........
Issued- ..........y5..)i.......... Date ............
DaW
THE COMMONWEALTH OF MASSACHUSETTS
BOARD(( OF HEALTH
iriU3YEof'..................................................... )
Ter#ifirw of fauutpitli trr
THIS IS TO CERTIFY, That the Individual Sewage Disposal System constructed ( ) or Repaired (�)
by------ f'F .... .. . .... -- ....: ..--- ------------------ ......------•------... -- ----• ---- .............
r '1 / Installer
has been installed in accordance with the provisions of TITLW 5 of The State Sanitary Code as described in the
—
application for Disposal Works Construction Permit No__, 1..-._:_.zs .%------------- dated..... �...::.;......................
THE ISSUANCE OF THIS CERTIFICATE SHALL NOT BE CONSTRUED AS A. GUARANTEE THAT THE
SYSTEM WILL FUNCTION SATISFACTORY. 4
DATE ... 4 .. Inspector <