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App-Permit-Compliance
G4 P4 O x w U No.._.. Fus......... THE COMMONWEALTH OF MASSACHUSETTS BOARD OF HEALTH .......................... 71-0 F... Y ................-•••-•---.------.....---.._.....--------................---•-• Appliration for Disposal Works Tnnstrnrtion Vrrmit A lication is hereby made for a Permit to Construct PP System at: ) J ............................. tion - Address -tl © -�.e -�"-- ............................ - _. r----•................... ............6 ._-___................ Installer ) or Repair ( C ►a Individual Sewage Disposal • Lor" v L4 8 rn•AP-33 -------------------or-- t-- --•--- ............ .._._........__. or Lot No. Type of Building Dwelling —No. of Bedrooms ................................. _.......... Expansion Attic Other —Type of Building ____________________________ No. of persons ................... Address Address Size Lot____________________________ Sq. feet Garbage Grinder ( ) Showers ( ) — Cafeteria ( ) Otherfixtures------------------------------------------------------------•---------------------•------••------••---•....----•-----•-......------ .................. Design Flow -------------------------------------------- gallons per person per day. Total daily flow -------------------------------------------- gallons. Septic Tank — Liquid' capacity___.__ -_____gallons Length ................ Width ................ Diameter ................ Depth_______..___._.. Disposal Trench — No . .................... Width .................... Total Length .................... Total leaching area .................... sq. ft. Seepage Pit No --------------------- Diameter .................... Depth below inlet .................... Total leaching area .................. sq. ft. Other Distribution box ( ) Dosing tank ( ) Percolation Test Results Performed by -------------------------------------------------------------------------- Date---------------------------------------- Test Pit No. 1 ________________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 Soil__________________________ ----------------- Nature of Repairs or Alterations ----•••------•-•----•-------- � avv --•-•------------•-•--•---••-•-----------•-•-------••-------------- - 1----------------�-�---�-L Answer when applicable -�..---------- a ------------- ___------- ----------------------•-----•--.....-----•---------•--------------•--------•-•----------•---•--------•-----....-•--------------------------------•----------------•--------------------.._.........- Agreement : The undersigned agrees to install the aforedescribed Individual Sewage Disposal System in accordance with the provisions of TITLE 5 of the State Sanitary Code — The undersigned further agrees not to place the system in operation until a Certificate of Compliance has been iss ed by the board of health. ./�_ Signed-•-••- ------- ----- ----- ----------- -.............................. ...- •--- --- Date Application Approved By--•• =---•----------------•-----•--•-------- -----•••-----•-----•-------------•--•--- Date Application Disapproved for the following re ons: - - •-------------------------------------------------•------^-------------------------.._....-------•-----•-----------------------------------•---- --••---•---••---�-..... ---D ----•-••••------ Permit No ------------ 3 Issued_ `}10..�...�--.... ---------- D THE COMMONWEALTH OF MASSACHUSETTS -B}-.OARD OF HEALTH ..................................... ..1.. O F....�............................................................... _....... _...... Tntifirate of Tomptiaurr THIS IORTIFY, That the Individual Sewage Disposal System constructed ( ) or Repaired ( ) ------------------------------------------------------------------------....-----------------------..._.._....---..__.....-----•--------------------- Installer N------------ - ------ --- at ---•-----_-----------y J .........•••- -- has been installed in accordance ith the provisions of TITLE application for Disposal Works Construction Permit No-_____-____. 5 of The State Sanitary Code as described in the ------------------------ dated ----------------------------------------------- THE ISSUANCE OF THIS CERTIFICATE SHALL NOT BE CONSTRUE® AS A GUARANTEE THAT TH SYSTEM WILL FUNCTI SATE FAC ORY. DATE--------------- - ------ •--------------- Inspector.