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App-Permit-Compliance
TAKIVIVUTM HEALTH DEPT. 1146 Rte .1T9 28 No...:!-7-�- - © SO. YAP 10U7H, MA 02664 FEs. `�.._........._ f THE COMMONWEALTH OF MASSACHUSETTS BOARD OF HEALTH ..........................................OF..."-( Z0..i t F'..------..-.....-.----------------------..-..-----. Appliration for Disposal Works Tonntrur#inn 1hrnti# Application is hereby made for a Permit to Construct ( ) or Repair an Individual Sewage Disposal System at: 22 Ys�''�,,t -•• flr ••• "1ec 1.aT:= ..0 .. ...... Locati • Address or Lot No JAMes,� ca• ....._.. -- ��_l��"D�-e�-mac... ---- •- ner Address % Installer Address Type of Building Size Lot ............................ Sq. feet Dwelling —No. of Bedrooms............ R -------------------------- Expansion Attic ( ) Garbage Grinder ( ) Other — Type of Building ............................ No. of persons............................ Showers ( ) — Cafeteria ( ) Other fixtures ........... 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 .-------------------------------------------------------------------------------------------------------------------------------------------•-•--_--• .......---------•-----................------------ /c'cC, -------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------••---•---•_-. Nature of Repairs or Alterations —Answer when applicable. ".D. A.9R�- �!!� _r7_�t .....T 4 L ._.�_- 6! ..__. Cmk5PSE= . .................................................•--•-... Agreement: The undersigned agrees to install the afore ed Individuak.ed e Disposal System in accordance with the provisions of TITLE 5 of the State Sanitary od — The undersirther agrees not to place the system in operation until a Certificate of Compliance has bee i sued by the boalth. Application Approved Application Disapproved for the Permit No ....... �o2-Zc) ........................... 7 --------------�!...._.a._.. a ------` ate . ._....------•-------------•-•---......•------•--•-----------......---------------•--------...._......._......I ---------------------------------•---•-----•-----------------.....-•••---------........................... j� ........ Issued------' ..!_... _... Date .......Date THE COMMONWEALTH OF MASSACHUSETTS o' BOARD OF ............. HEALTH '..��:.- ......... OF.....`..`i-.a �.0 i'F:.................................................. .. Trrtifiratr of Toutplittnrr THIS IS TO CERTIFY, That the Individual Sewage Disposal System constructed ( ) or Repaired (, ) by... E=.r' . .� ._. tom. ..t�.xgr..... . Installer at__...�" �_:. ^c`��-t A A.� +f-" �.��•4 °• ..!r.�(? (1.._._�'_�'_,'.�__Y �_�•7_SC_.e�___••__•-_._•._____ has been installed in accordance with the provisions of TITS 5 of The State Sanitary Code a de c ibed in the application for Disposal Works Construction Permit No ------ ............. da.ted....._._i�,..�__..��:�': _.� <!........ THE ISSUANCE OF THIS CERTIFICATE SHALL NOT BE CONSTRUE® A;VA GUARANTEE THAT THE SYSTEM WILL I FUN T,N SATISFACTORY. DATE.......... rg.t..101.6„d.i:I.................... --------------------- Inspector ----=-......;-......":= --- ........ '. ........................................