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App-Permit-Compliance
No. �__r..': ZZ .. FEs.. $15 .............. THE COMMONWEALTH OF MASSACHUSETTS BOARD OF HEALTH ...... T.C411,1............... OF.......we Applirtttion for Diaposal Works Tonotrortion Fermi# Application is hereby made for a Permit to Construct ( ) or Repair ( ) an Individual Sewage Disposal System at: .......... .o..p........................................... .................................................................................................. J o®cation - 4ddress a,e?.z'4._.._.................................... �— Q 2!� ft�-� fd Z............-•-.........----- ......... ..............e . ....._._.... Owner Address .... ..... ..... /y ............................ Installer Address Type of Building Size Lot ............................ Sq. feet U Dwelling = o. of Bedrooms ------------------------------------ -----Expansion Attic ( ) Garbage Grinder ( ) U '4 Ot er — Type of Building ............................ No. of persons ............................ Showers — Cafeteria Q' Other fixtures .----•-----'•-'-......----•----•-..._-'-•-...._ W Design Flow -------------------------------------------- gallons per person per day. Total daily flow ............................................ gallons. WSeptic Tank —Liquid capacity ............ gallons Length ................ Width ---- _........... Diameter ................ Depth ................ x Disposal Trench — No ..................... Width .................... Total Length .................... Total leaching area -------------------- sq. ft. Seepage Pit No._f at_ . .... Diameter-__ - �! ............. Depth below inlet. -a. ............ Total leaching area .................. sq. ft. Z 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 _-__.-_--_-_____--..___. f� Test Pit No. 2 ----------------minutes per inch Depth of Test Pit ............... ..... Depth to ground water ........................ P4....................... _.._....__._....__..._.__............._._.._..........._----._....--------•-......................................................... ODescription of Soil ................................................................................ ---......................................................... ...................... ---------------------------- ------------------------------------------------------------------------------------------------------------------------------------------•'------------------------------- W ......................... j - U Nature Repairs Alterations able... ...1 Answe when a liv'D_. ..___h C C' a� Agreement : V The undersigned agrees to install the aforedescribed Individual Sewage Disposal System in accordance with the provisions of iITIE 5 of the State Sanitary Code — The undersi ped further agrees not to place the system in operation until a Certificate of Compliance has by t bo d o th. Signe _.---'-•-- ---" '-....... .�i{ S13 S Application Approved By ..... -- - � •------------ ---------------------------•-------------�-------------..... Date Application Disapproved for the following reasons:--'-•'--------"•-"-'-"-------•'-'•-•-•---•-•-"--•-••-------------------------------------•-•'-•-'-•••....... ........................'•-------•-----'•'•'--"----......_._..----.....__.._........---•-••-•-••••--•-----------••----••-------"'-----_...----...-'••'----'•-'•...... ............................... Date Permit No.__ � _rJ___.. Z s--------------------------- Issued----- .5�3 ....................... Date ------------- THE COMMONWEALTH OF MASSACHUSETTS BOARD OF HEALTH .......................................... OF .................................................................................... (9rdifiratr of T-nutpHattrr THIS IS TO CERTIFY, That the Individual Sewage Disposal System constructed ( ) or Repaired by_ ---•-------•--------- Installer CY ,�. Cce has been installed in accordance with the provisions of TITLE 5 of The State Sanitary Code as descrjbed in the application for Disposal Works Construction Permit No. 3� _> _`- ----------------- ....... dated__. �................. THE ISSUANCE OF THIS CERTIFICATE SHALL NOT BE CONSTRUED AS A GUARANTEE THAT THE SYSTEM WILL/, FU CT�ION SATISFACTORY. DATE ........ �` (���• ©VS---------------------•-----------------•---- Inspector ----- ..... �-