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App-Permit-Compliance
No.... Fss.....°� ` THE COMMONWEALTH OF MASSACHUSETTS BOARD OF HEALTH To.GUAJ.............OF......... F!.eM...©.c.,?.7?.V.................................. Appliratiun for Dhipaiial Works Tianritrur#ion Prrmif Application is hereby made for a Permit to Construct (,W) or Repair ( ) an Individual Sewage Disposal ' / System at: Location-}(ddrns or Lot No. Address �: W ......`J .L! i!t-' ...................................................................................................................... Installer Address Type of Building Size Lot...l._dL'�/...Sq. feet Dwelling —No. of Bedrooms........................................Expansion Attic ( ) Garbage Grinder ( ) Other — Type of Building ................. No. of persons ............ ............ .... Showers ( ) — Cafeteria ( ) Other fixtures.....................................................-...... ........... .---......................... ....... ..................................... .. Design Flow .............:` ...................gallons per person per da.7. Total daily flow..............�r''....G5L5. ..............gallons. Septic Tank — Liquid capacity/.o.�.4� gallons Length.e.<.:`a..... Width .... Diameter ................ Depth....1g.. .'... Disposal Trench — No. ._ ................ Width .......... Total Length .................... Total leaching area .................... sq. ft. Seepage Pit No......./.......... Diameter ..... 1..O.:.6L-Depth below inlet ........4......... Total leaching Other Distribution box (,<) Dosing tank ( ) Percolation Test Results Performed by .... w CGc __/alG _- Date.... . ........... 5........ Test Pit No. L. _..minutes per inch Depth of Test Pit_..=..".. Depth to ground Co v,J7'�l" �A Test Pit No. 2................minutes per inch Depth of Test Pit..._................ Depth to ground water....._.................. Description of Soil...... 59'G-........1-3t:7'.T..l9:.c/rE:.4F_Z?------../: .6r...eQ---'................-----------....-----............................. Nature of Repairs or Alterations — Answer when Agreement: The undersigned agrees to install the aforedescribed Individual Sewage Disposal System in accordance with the provisions of TITIZ S of the State Sanitary Code — The undersigned further agrees not to place the system in operation until a Certificate of Compliance has been issued by the bo.'lyr- of hea'tlj! ) Sign d f ¢` / �/f C U: �C'.�y...%'..... J... .... Z. .......... _- Application Approved By.......... 4�G1 - .!?:V' . m ................................ _ z i -- Application Disapproved for the following reasons: .... ___ .................-----....----........---------...------------....................---- yk..1�J. 4 ) t Data Permit No.--------< ............................ Issued.......... .............. Date THE COMMONWEALTH OF MASSACHUSETTS BOARD OF HEALTH ................ OF .............................................................. -6 ................... Tntifiratr of f vmpfiattrj� t the Individual Sewage Disposal System constructed (�f) or Repaired ( ) j" r at.. .... ..._. t (' t ............... ..........L.............................-...... r ..... Y .... has been installed in accordance with the provisions of TITLE j of The State Sanitary Code as des ribed in the application for Disposal Works Construction Permit ...... dated. .... .... :.¢..2.a..../ ............... THE ISSUANCE OF THIS CERTIFICATE SHALL NOT BE CONSTRUED AS A GUAPANTE...THAT THE SYSTEM WILL FU T N SATISFACTORY. a (� r DATE .! 1!�''_........................................... Inspector------.