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App-Permit-Compliance
YARNIOUTI-i NPT. Town Oi is �?Z.... South Ya n,ou h, it;fi,. G�._,G=i FEB ...11 ............ THE COMMONWEALTH OF MASSACHUSETTS BOARD OF HEALTH ............... _.............. ........ O F....................................._................................................... Appliration for Disposal Iforks Tonstrnrtion Frrmit Application is hereby made for a Permit to Construct ( ) or Repair ( k -f -'an Individual Sewage Disposal System at: ....... R......_-....r.:�8 :x/__0l M......L....�w_ _......................... .................................................................'. ..1.C.i..,.3... ... oration - Address or Lot No. ..............Ctn. .. ........._......................---•--......--...... Addrrss .... Y.M.t...i'.. ........................ ........p't..: x�7tt�.r1. ....../ ,.c:a. ....._...................... .r-9 M Installer Addrew Type of Building Size Lot ............................ Sq. feet U Dwellin No. of Bedrooms...... . ...Expansion Attic Garbage Grinder Other—Type of Building No. of persons ............................ Showers — Cafeteria NOther fixtures ...............................................---............................................................ _ .................... 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. 3 Seepage Pit No ..................... Diameter ........... Depth below inlet.................... Total leaching area .................. sq. ft. Z Other Distribution box ( ) Dosing tank ( ) aPercolation Test Results Performed by......................................................................... Date .............. .......................... Test Pit No. I................minutes per inch Depth of Test Pit.................... Depth to ground water........................ tT, Test Pit No. 2................minutes per inch Depth of Test Pit.................... Depth to ground water........................ Description of Nature of Repairs or Alterations — Answer when applicable ......Y�.1 ]..._la.L1ct....P.3.......w.... 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 as-bissuedhebgaTd o . ealth. Signed.....-- --^.......... .. an ................................. - 16 Application Approved By-- rn-tt..... - .............. - �� 1.�.© (. tv�........ Date Application Disapproved for the following reasons--------------------------_.--------------.................------.....--------•--------.....-----•-•--•-••---- �y Date Permit No............. � z - Issued ..... Q'.1 I C� i Jc Date THE COMMONWEALTH OF MASSACHUSETTS BOARD OF HEALTH ............... ........... ........:......... ................ ............... Ttrtifirati of Tomplittnrt THIS IS „TO CERTIFY, That ,the Individual Sewage Disposal System constructed ( ) or Repaired 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 .......:10 7__ .............. dated... .....!..._..:'?`............................ THE ISSUANCE OF THIS CERTIFICATE SHALL NOT BE CONSTRUED AS A GUARANTEE THAT THE SYSTEM WILL FUNCTION SATISFACTORY. DATE....... ............ '--�................................................... Inspector .... ..-....1...... i::. ......... ...............................................