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App-Permit-Compliance
Fxs..... ;, 5 .............. THE COMMONWEALTH OF MASSACHUSETTS BOARD OF HEALTH ..-----.�.W..M.......... OF.............���............................ Appliration for Dhipoal Workg Tonotrnrtiun ramit Application is hereby made for a Permit to Construct (� or Repair ( ) an Individual Sewage Disposal System at: --... _...............• ------- --.....------------.......--•----••-- Location . Address 1 or Lot N .1.+�. t'U...................... �c .� ..... 1_.. Owner Address Installer Address Type of Building Size Lot .... / by___ 16._..Sq. feet ' Dwelling —No. of Bedrooms................._.__..___..._........_Expansion Attic ( ) Garbage Grinder ( ) Other — Type of Building ............................ No. of persons ............................ Showers ( ) — Cafeteria ( ) Otherfixtures------------------------------------------------------•--------------------------------- ............................................................. Design Flow .............. a`..................... gallons per person per day. Total dail flow.-_.....��.� ..._................._ gallons. Septic Tank — Liquid' capacity�C�©d.gallons Length. -.<6...... Width....-'.._. Diameter ................ Depth--- R .'....... Disposal Trench — No - -------------------- Width ........ .___..._.. Total Length .................... Total leaching area .................... sq. ft. Seepage Pit No ........ /------.._. Diameter._Z.a`....... _ Depth below inlet ---.4-......... Total leaching area'. ....... Other Distribution box (}X) Dosing tank ( ) Percolation Test Results Performed b ._ d .. 4JI04.4th l� / �-�............ Y , ............. *....� Date Test Pit No. 1 ...... 5 ....... minutes per inch Depth of Test Pit... . ... Depth to ground water.�L?�T.EN' Test Pit No. 2 ..... ...... minutes per inch Depth of Test Pit... 4�.4!21. Depth to ground water.410V 6A TPZ 47�' --------------------------------------------....... -.... --•--....------------ Description of Soil ------ r5_e"�------ t ft .A........ P �i.'`f! .----------------------------------------------------------------------------------------------------------------------- ------------------------------------------------------------------------------------------------------------------------ Nature of Repairs or Alterations — Answer when applicable ............... Agreement: The undersigned agrees to install the aforedescribed Individual Sewage osal System in accordance with the provisions of TIT LE 5 of the State Sanitary Code — The u dersign Sewage t e agrees not to place the system in operation until a Certificate of Compliance has een 'sued by t bopd 1 - Signed------------------------/ .--................................ Date Application Approved BY. ' L'�..-- • - - Date Application Disapproved for the following reasons--------------•-----------......----------------•-----•---------------------•---------•-----•----•---........... Permit No.... /`3` S -------------------------- Date Issued.....- . ...................... Date THE COMMONWEALTH OF MASSACHUSETTS BOARD OF HEALTH ................... ..t'.rF:r✓....OF? .✓:`................................................... (�rrii�irtt#le n� f��ant�it�tnrr THIS IS TO CERTIFY, That the Individual Sewage Disposal System constructed (� )' or Repaired by.... --•..z ...... 0.-Lx�_ ' e ---------------------•----------•----- - ... ...._...... ..... Installer at--- ;,� .- — ----j �4.l----r�• '��.� w�`= =--------------------------------------------- I ...............-----------.....----------•--------------- -•-- - . - 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 -••-------- dated:_ -y ..... r;j.._.:3 .................. THE ISSUANCE OF THIS CERTIFICATE SHALT. NOT BE CONSTRUED AS A GUARANTEE THAT THE SYSTEM WILL F//UNCTION SATISFACTORY. DATE.........C� _:�11-_=.r� ��i"----------•--- ---------------•-----•-------•------------.._.. Inspector- ---•---•---......