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App-Permit-Compliance
r NO..V.33a '- FE$.....°�S d THE COMMONWEALTH OF MASSACHUSETTS BOARD OF HEALTH .Ll_ZLO/1�.................. OF ........... <..H% 1 _ ._..........._.........._.._... Appliration for Disposal Warks Tnnstrurtinn tiverutit Application is hereby made for a Permit to Construct (X') or Repair ( ) an Individual Sewage Disposal Svstmn at - T 6'/ mIC4P-LkO ---------- ocation - _Address or Lot No. L 1�-------�--r- ` 1 v.,............... �K .... - - --- --------------------------------- -------------- Aa wner dress ;V --- ............................----•.... ---------------- Installer Address Type of Buil ngSize Lot ... ©f..............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 dail flow___..._. -......2.Z .............. gallons. Septic Tank — Liquid' capacity/ -O 0!'.gallons Length --Z•-45'-'- Width.......!.... Diameter________________ Depth ----- 6.7 `... Disposal Trench — No ..................... Width .................... Total Length .................... Total leaching area .................... ft. Seepage Pit No ....... f........... Diameter.._.1�...4�. Depth below inlet ...... -. �...... Total leaching area�`�g�_..1�!'/� Cr_ Other Distribution box (X) Dosin tank ( ) Percolation Test Results Performed by . .._ .._.� �-..-E`Z lA� Date__. ''./(�. .................... Test Pit No. 1-.-<Z__ .... minutes per inch Depth of Test Pit._A. Depth to ground waterNdtr E-!� , Test Pit No. 2................minutes per inch Depth of Test Pit .................... Depth to ground waterc�.__ _.....v ....- ,V17i2Ev . ...... _._ ---------------------------------------------------------------•----------- Pescription of Soil...------�E .....4.--T--'T <1--AAF.a.b------P-!&.4-------=------------------------- •--------------------------------------------------------------------------------------------------------------- -----------------------------•----------------------------.....-----••-•---......----- 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 TIT 12 5 of the State Sanitary C e — The undersigned further agrees not to place the system in operation until a Certificate of Compliance has be sued t board of health. Sign. -•........... ....................................................... � ._ t Application Approved BY-- :........ . •-• --- ...................................................... -----�--�=-�-..-------- Date Application Disapproved for the f ollowi g reasons:------•--------•-•-------------------------------........................................................... Permit No.. .(�-3 �----•--•-------_.... --------------------------------------•---...-•-----• •---•-----.... Date Issued _.-------���•`•-�-- --. ----------- Dat THE COMMONWEALTH OF MASSACHUSETTS BOARD OF HEALTH .......................................... OF ........................................... Grfifira tr of Toutpliattrr THIS IS TO CERTIFY, That the Individual Sewage Disposal System constructed ( ) or Repaired ( ) by....................•---------•----..........--•--•---•----------....----•-•-----------•-•-•-------------.....----------......---------...----.....---.....-----•----------------------------- Installer at_.__._... 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 No ......................................... dated .......................... _..................... THE ISSUANCE OF THIS CERTIFICATE SHALL NOT BE CONSTRUE® AS A GUARANTEE THAT THE SYSTEMA WILL FUNCTION SATISFACTORY. DATE............................................................................... Inspector.