App-Permit-Compliance..........
THE COMMONWEALTH OF MASSACHUSETTS
BOARD OF HEALTH
........................... OF ..... r..IfYVOIA.�.....................................
Appliration for Disposal Works Tontrnrtion jhrmit
Application is hereby made for a Permit to Construct (�}' or Repair ( ) an Individual Sewage Disposal
4.'Da"� 1=:a miab Zo S. yi mq.
Location - Address or Lot No.
.................••-----.._..... `. .
Owner Address
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..... — �..... * .......----••--•............................................... ........ .........•.......-•-•-----•-------•-----•-••-••-•--............-•--•-•---•----•-----......••------
Installer Address O�
Type of Building Size Lot._.__...�..................Sq. feet
Dwelling —No. of Bedrooms ............... �.5........................ Expansion Attic ( ) Garbage Grinder ( )
Other — Type of Building ..:......................... No. of persons ............................ Showers ( ) — Cafeteria ( )
Otherfixtures ......................... r��--------------------------------------------------------- ----•------------------------------------------------
Design Flow ..........__ 1..1.0......................gallons per pe"Q -,per day. Total daily flow ........... .�?................ gallons.
Septic Tank — Liquid capacityL=---gallons Length8-11:C". e'.... WidthA-. Diameter Depth•....-4-...
Disposal Trench — No ..................... Width .................... Total Length .................... .Total leaching area .................... sq. ft.
Seepage Pit No ........ 1........... Diameter.•.._ 1 D........ Depth below inlet ....... 6 a....... Total leaching area.. l.... sq. ft.
Other Distribution box ( ) Dosing tank ( )
Percolation Test Results Performed by._.k.}.Ck.i.A:____...________________________ Date .....
Test Pit No. 1..4n:-.__..minutes per inch Depth of Test Pita `...... Depth to ground water_. ........?-�i
Test Pit No. 2................minutes per inch Depth of Test Pit.................... Depth to ground water .........................
t� U
of
.....1._. .............---................................ .........._-.............. �.._._T. ......... ...........-.................................................
......`..........................................................................................................................................................................•....._.................
Nature of Repairs or Alterations — Answer when applicable...............................................................................................
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Agreement:
The undersigned agrees, to install the aforedescribed Individual Sewage Disposal System in accordance with
the provisions of TITI1Z- 5 of the State Sanitary Code e undersigned further agrees not to place the system in
operation until a Certificate of Compliance has beea+ bS�f lth.
Application Approved
Application Disapproved for the f oll
.... ................................
{Date
.............................................. _................................................................. _................................... ----------- -----------•----- •---------------
Date
PermitNo ......................................................... Issued .......................................................
Date
THE COMMONWEALTH OF MASSACHUSETTS
BOARD OF HEALTH
................................. ....... OF,\.............................................................
C�rrtifir tr of (rontplianrr
THIS IS TO Y.7,FYhat the Indvidual Sewage Disposal System constructed (�) or Repairedby........................� �f ...------------
Installer ('
`.:++�`
has been installed in accordance with the provisions of TITLE 5 of The State Sanitary Code a des ibed in the
application for Disposal Works Construction Permit iv'o.__._1..�__�__!_ �'. _ _... dated___ _ ._�,1_ . .............
THE ISSUANCE OF THIS CERTIFICATE SHALL NOT BE CONSTRUED AS, A G`U AN EE THAT THE
SYSTEM WILL F NCTIO SATISFACTORY.
DATE ! Inspector -- ... ,----- -.........................................
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