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App-Permit-Compliance
E ' ✓ " N� 3 .57Fes..�:s ............ THE COMMONWEALTH OF MASSACHUSETTS BOARD OF HEALTH ............... OF ............. fP aC1. Appliration for Disposal Warks (fnnstrnrtion jhrmit �7 � �✓ � Application is hereby made for a Permit to Construct PC) or Repair ( ) an Individual Sewage Disposal System at: - ..... - $( - o 1_...�... Location - Addresr Lot No. , �e2 =----------------............................ ...... / / Owner Address Installer Address UType of Building Size Lot ............................ Sq. feet Dwelling —No. of Bedrooms ........... 3............................Expansion Attic ( ) Garbage Grinder ( ) "P14 14 Other — T e of Building ............... No. of persons....___.....-:_.._..._...... Showers — Cafeteria � Other fixtures---------------------------------------------------•----------------•---•-----•--•-------------------------.....-----------•--......... W Design Flow...............:�_�................... gallons per person per day. Total daffy flow ........... .... �--__.-G?-.--.....--.......gallons. WSeptic Tank —Liquid* capacity/0 gallons Length___ �. `.._.. Width....`.... Diameter ................ Depth............ x Disposal Trench — No ................ Width ...... Total Length _.._...._.__._. ._. Total leaching area .................... sq. ft. Other e Pit Distribution box Diameter...... O ._ tank below inlet ....... r.__...... Total leaching area�6/'.. .sq- . <g •%may ©. Z (D<) g ( )- 1.4 Percolation Test Results Performed by__.�___-..-WEL... Date...._-�_:"�_____. ,.a Test Pit No. 1 _ z -._._minutes per inch Depth of Test Pit.1_4.19_._..... Depth to ground water Af? -_- ' �ea� i:;— iFZP f=, Test Pit No. 2................minutes per inch Depth of Test Pit -------------------- Depth to ground water ........................ ........................................................... -- ........---.................... ---------- Description of Soil =5...-�-..'J.----- i�'� -------------------------------------------............................................................................................................................................ 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 TITLE 5 of the State Sanitary Code — The undersigned further agrees not to place the system in operation until a Certificate of Compliance has be b e board e t� Q Signed _ Application Approved By. .. r -------- ------------------- ...... I =Zli ......... _...._.. . Date Application Disapproved for the following reasons: ............. . •-------------------------------------•---------.................._....... -------------- ---•-------------------------• •.......................................................................................................................................................................... Date Permit No.... .- ............................. Issued ...... 1..:12 ---P 3 ..................... THE COMMONWEALTH OF MASSACHUSETTS BOARD OF HEALTH c :�.. / OF. j/'r�',c/� '............... �..:....................................................................... Tnrtifiratr of Tompliaurr THIS IS TO CERTIFY, That the Individual Sewage Disposal System constructed K) or Repaired ( ) y------ - _Installer at fti 1' ._ (_.....- G C.� 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._P..3__ :--- .... 5_ --------------- .....- dated ---- -�---53- ------------------- THE ISSUANCE OF THIS CERTIFICATE SHALL NOT BE CONSTRUE® AS A GUARANTEE THAT THE SYSTEM WILL FUNCTION SATISFACTORY. DATE ........... --=--� ` �� Inspector---- "