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App-Permit-Compliance
g' No.. ... FEs.,... . .... ............ THE COMMONWEALTH OF MASSACHUSETTS BOARD OF HEALTH ----------- ----...... .................... O F .................. ........................................................................ , ppliration for Disp.agal 10orkti Tontrurtion Famit Application is hereby made for a Permit to Construct ( ) or Repair (< an Individual Sewage Disposal System at: .................. 1� ....._� -... h... ._...., �%.....'-._...,....... "• �g % Locat' n • Address o Lot No. J ^7 6 ........ _..... l�_l.L. .....• ----'•...1 �_` . ........................L _7-.... Owner............................................ Address Installer Address Type of Building Dwelling —No. of Bedrooms ........... Other — Type of Building .............. Other fixtures .................... Design Flow ----------------------------------------+--ga Septic Tank — Liquid capacity ............ gal Disposal Trench —No - --_----_--___--_-- Wid Seepage Pit No --------------------- Diameter.._.. Other Distribution box ( ) I Percolation Test Results Performed Test Pit No. 1................minutes per Test Pit No. 2................minutes per Description of Soil___ Size Lot ............................ Sq. feet -----------------------Expansion Attic ( ) Garbage Grinder ( ) )7---_ o. of persons____________________________ Sho ers ( ) —Cafeteria ( ) - ---- •-----------------.••--••---•------------•--------------•-•-----••--•-----•... ................................ eperson person per day. Total daily flow ------- ------------------------------------gallons. ength_------------- Width ................ D'am er--- ------ Depth ................ Total Length__ .._...._../ ota ing area -__--.--------------sq. ft. --_ Depth below inlet-_ --- -- ____.Y. '.0 otal leaching area .................. sq. ft. to ( ) ----------- ---------- Depth o Test Pit....._.. Depth of Pit-------- ----------------------- Date ......................... -------------- Depth to ground water ............... ......... Depth to ground water ........................ .-------------------------------------•---•----•--------------------•-•------------•----...------•---.... . •-------------------- ............................................ -------------------------------------------------------------------------------------------------------• ----- - --•-•----------•-- Nature of Repairs or Alterati�s Answer when applicable_""___ ..: __ 1 Q/�-.•.---. ................................................ =� r---•--------------------•------------------------- -:3x •-------------•-- -•-•- Agreement: ' The undersigned agrees to install the aforedescribed Individual Sewage Disposal System in accordance with the provisions of 'TTL, 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_ Application Approved By ................................................... Application Disapproved for the following reasons: ........ Permit No. .......... ................................ Date -------------- ......................... Date -----•-------------------------------------------------------------------------------- -------------------------------------------------------------------------------------- Date Issued--------------------------------------- --------------- Date THE COMMONWEALTH OF MASSACHUSETTS BOARD OF HEALTH �.r��.^... .........OF......... �1?©v lL�................................. Trrtifirtt of Tontlilittnrr THIS ISS}TO—CERTIFY, ,/�That t%j Individual Sewage Disposal System constructed ( ) or Repaired ( by l-" ------ -- �+'/�...'..... In --------- --------------- -- ` at-- ��----•--- ` J ---------•--- - /� SG /( ...... ....... L... - - . has been installed in accordance with the provisions of TI 5 of T e tate Sanitar Cor_Rf s d/ cr' ed in the application for Disposal Works Construction Permit No ......... .... .................. dated ----- .__THE ISSUANCE OF THIS CERTIFICATE SHALL NOT TRUED AS A G T E T T TIME SYSTEM WILL F NCTIO SATISFACTORY. Ins ecto ...__ - - -- -- ----- ........ DATE , P ;