App-Permit-ComplianceNo.r./V
THE COMMONWEALTH OF MASSACHUSETTS
BOARD OF HE LTH
oF....... t------ ------------------------------- ---------
App iration -for Diopma1 10orko Tutuitrnrtion Prrntit
Application is hereby'made for a Permit to Construct (,,�/or Repair ( ) an Individual Sewage Disposal
System at
......'...
hS Location -Address or Lot No.
C/ �1�.-------------------_-____ ...1 GS 1 `l.
Owner � � � Address /
a�
Installer Address
Q feet Type of Building Size Lot____________________________S q.
VDwelling — No. of Bedrooms___________________ _ __ ..__.Expansion Attic ( ) [ Gar age Grinder ( )
'L e
p� Other — Type of Building(,,
rJ�%v71__.No. of persons._______ Showers ( —Cafeteria ( )
Other
fixtures ------------------------------------------------------
Design Flow___.___ r�______i!��___-gallons per
person pere day. Total d-ailyflow.......... 3.-3-0 __.__._.__ ____.-_._gallons
.
R'Septic Tan — Liquid capacity/426--- gallons Length ---- gWidth__6_._ Diameter_____Deptll..r_5;?Y..
Disposal W—No-
_----- r------___--- Width --- x -Z----------- Total Length --- 3s_........ Total leaching area. ---if ZP._.___sq. ft.
x
Seepage Pit No._____�t ''Diameter________________ Depth below inl@t-- __________ Total leaching area---- _____sq. ft.
Z Other Distribution box ((/� Dosing to lc
Percolation Test Results Performed by------'1� 115 ,P O 't ---------- Date__�Z?/77�----��-----
Test Pit No. 1_-riunutes per inch Depth of fest Pit ....�_�____ __-. Depth to ground water....5-_3--__._--..
�i Test Pit No. 2 ................ minutes per inch Depth of Test Pit .................... Depth to ground water ------------------------
---------------------------------------------------------------------------------------------------- ------------------------•--•---•------------------------
O Description of Soil ------- ......... 4____--._`____._----------------------------------------
x
V-•--------------------------•--•---------------------------------- -------------•-----------------------•------------------------•---------------•--•------- ------------------------------------------
W••-------------------------------------------------------------------------------------------------------•-•--••----•••---------------------------------•••---•-•--------------•----•-------------------
VNature of Repairs or Alterations —Answer when applicable ------------------------- _----------------------------------------------------------------------
---------------------------------------------------------------------------------------------------------- •----------•-----------•------------------------•----------------------------------------
Agreement:
•--------------.__..------------------Agreement:
The undersigned agrees to install the aforedescribed Individual Sewage Disposal System in accordance with
the provisions of Article XI of the State Sanitary Code — The undersigned further agrees not to place the sy tem in
operation until a Certificate of Compliance has bee is ue th board f health.
i/ Signed ----- #l 9
Application Approved By_........._.Z.__.... N 5 -- ------------ =' -
Date
Application Disapproved for the following reasons: -------•--------------------------------•--•-----------------•--------•----------------------•----•••-----------
------------•--------•----------------------------------------------------------------------------------- -•---•-----------------------------------------------------------------------------------------
Date
Permit No ...................
Issued.......................................
Date
THE COMMONWEALTH OF MASSACHUSETTS
BOARD OF HEALTH
.......................................... OF .....................................................................................
�
rrtifiratr of Tontplianrr
THIS I CEI jIFY, That the Indio• al Sewage Dis al System constructed („s<-) or Repaired ( )
by----_----- - >� _.. e 4-- - 1 -�.....
Install r J
at ------------- -- -,,4L- &/!'------- �
has been installed in accordance with the provisions of Article XI of The State Sanitary Code a des ribed in the
application for Disposal Works Construction Permit No._'. _.____________
j� dated---------- - --°`
THE ISSUANCE OF THIS CERTIFICATE SHAL�NOT BE CONSTRUED AS A GU RA EE THAT THE
SYSTEM WILL FUNCTION SATISFACTORY. '�"�'`�
DATE................................................................................ Inspector---•-----
(