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QQS-246
No..S1... '----'--------- F�s.�.ZJ�.........
THE COMMONWEALTH OF MASSACHUSETTS
BOARD OF HE..,lA._ LTH
.................O F....... a .0 �?.'� D...G1..;?.-•----•---..-....--------_----_--.------.
, ppliration for Disposal Murks Tonstrurtion Frrutit
Application is hereby made for a Permit to Construct (X or Repair ( ) an Individual Sewage Disposal
System at:
.. .�i �:7t2....... t`1.v .....------•------••-------••-•------------------ - --• ----1 a&•--•--••--. --`-• ��
/t 1 I,�ocation - Address or Lot No.
"_......'_'V1- -_ � ...Ownez........ ---^......_.......•
.- Address
-----•-----------•---------------•-----•-- .. --...........
. Installer Address
Type of Building Size Lot... /2j.-1 / 8.Sq. feet
Dwelling —No. of Bedrooms-----\3..................................Expansion Attic ( ) Garbage Grinder ( )
Other — Type of Building ............................ No. of persons .................. 0......... Showers ( ) — Cafeteria ( )
Otherfixtures ..................................... -.......... ---..........................
Design Flow ............ c Ls ......................gallons per person per day. Total daily flow ....... oo-_3-.J._O._....._._..__......�1 lops.
Septic Tank — Liquid' capacity/—POL?gallons Length .... 6--------- Width..y;---_-..... Diameter ................ Depth -._L/,........
Disposal Trench — No ..................... Width .................... Total Length .... -............... Total leaching area .................... sq. ft.
Seepage Pit No ........ /.----------- Diameter ...... %2r._..... Depth below inlet ..... Y�......... Total leaching area-__ Par; sq'ft. p,
Other Distribution box ( ) Dosing tank ( )
Percolation Test Results Performed by ................................................... .. Date........................ 0 ...............
Test Pit No. l ... 2_2 _..minutes per inch Depth of Test Pit .... Z 1.0...... Depth to ground water.1_p.... �yz_O__
Test Pit No. 2 ----------------minutes per inch Depth of Test Pit .................... Depth to ground water...(—.Ovq`�eP
.................. =................................................................
Description of Soil----- .............................................................
...................................................... .---------- ----------------- ................................................
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 TIT1�, 5 of the State Sanitary Code — The undersigned further agrees not to place the system in
operation until a Certificate of Compliance has be�issuedl. by t o rd Ie lth.
Signed.. ...... ....... ... .......... .......................... 1� `D .
Application Approved By--- w.1L --c� %----------------------------------------------- ............ ! ..............
Dattee
Application Disapproved for the following reasons: -----•--------•--•-----•----------------------•----.....------......-----------•------..........--•-••----------
.........................•---------...-•- •---•-------• •-••-------.........--------------........-----.....--------------.............--•-------------••-•-•--------....-•--• •---•-------....------------.
Date
Permit No.... .�4..amJ-------------------------- Issued ........ E -l! !--
.........................
Date
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I"
THE COMMONWEALTH OF MASSACHUSETTS
BOARD OF HEALTH
...................7................. OF.....;1................................................................................
Trrtifira#le of Tompliaurr
THIS IS TO CERTIFY, That the Individual Sewage Disposal System constructed (�- f ` or Repaired ( )
by....C_-... �? r4 ==`-----------------------------••-------•-•-------•------• .
.aa if I Installer
at �'E--------- --------------
has
4=-•----- = '' = ` ,- _
--------------------------------- ------•--•-----------------•------•------------------•--------------------•--------------------
has been installed in accordance with the provisions of TIT 1 f The State Sanitary Code as de ribed in the
application for Disposal Works Construction Permit No --- -_------ `!-�.............. dated..... �-�°...!-�. t
--------- ....................
THE ISSUANCE OF THIS CERTIFICATE SHALL NOT BE -CONSTRUED AS A GUARANTEE THAT THE
SYSTEM WIJLL FUNCTION SATISFACTORY.
DATE------.. °`� ,", Inspector.. ,I "