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THE COMMONWEALTH OF MASSACHUSETTS
)BOJARD OF HEALTH
./." .... OF... ....... ...e.`:.................
Apphration for Movaliat nrkD Tonstrnrtinn Permit
Application is hereby made for a Permit to Construct ( ) or Repair V_j an Individual Sewage Disposal
System at
.LOT- _1.12 ....... iM f P-8 !e
.. .. ..
N
ation rAddre! or Lot o.
.. d. —. .....1.',l,r 1 %�1��.. - ..... Q_.�..............3. Jac- ' ...._------------ ...
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WLc.l L�%•.�-•=...... i.l... � .. .................... ddreas......:.
a Installer Address
Type of Building Size Lot ............................ Sq. feet
RDwelling —No. of Bedrooms......................................Expansion Attic ( ) Garbage Grinder1-4
( )
....
'k
a Other — TyP e of Building No. of persons ............................ Showers ( ) — Cafeteria ( )
p+ 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.
3 Seepage Pit No ..................... Diameter.................... Depth below inlet .................... Total leaching area .................sq. ft.
Z Other Distribution box ( ) Dosing tank( )
0.0 Percolation Test Results Performed by.......................................................................... Date ........................................
,1.4a Test Pit No. 1................minutes per inch Depth of Test Pit.................... Depth to ground water........................
Test Pit No. 2................minutes per inch Depth of Test Pit .................... Depth to ground water ........................
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ODescription of Soil ........................................................................................................................................................................
W-•------------------------•---•------•---•----...............__--•------•-•---•......................................................_...
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U Natur of Repairs or Alterations — Answer when applicable../`/ j.....: - Sj .�l1,� .-..../ £Q
.� .Z ,4.1/_c�I Ssa?,.................•--------•-•-----......-----•----•-------....----------------•----•-•-------------••-------•-•-----...---...-----.................
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 has been issued by the board of heajtly
Signed.: .. ...l :.l.<< .................. ...� D-•---
Date
Application Approved By--- ......... .........................••••----................................ ....---•� - Q_ -..s' .....
Date
Application Disapproved for the following reasons: ..........................................................................................-•--.-----•-----
........................................................................................ _............._................................................ ............................................
Date
Permit No._ Y.:: ��.,1...... _......... _..........
Date
THE COMMONWEALTH OF MASSACHUSETTS
BOARD OF HEALTH
faPrtifirtttp of f ompliana
THIS IS TO CERTIFY, That the Individual Sewage Disposal System constructed ( ) or Repaired
/ ... / j
by....... ..... - ---• .--••.. ......-----•..............•-- .................................................. .......
! Installer
at. •--------•--• • ........... ... •----•-- ..............1....................................................
has been installed in accordance with the provisions of TITIEE j of The State Sanitary Code as described in the
application for Disposal Works Construction Permit No.._. ..................... .................... dated ...... _:............................................
THE ISSUANCE OF THIS CERTIFICATE SHALL NOT BE CONSTRUED AS A'GUARANTEE THAT THE
SYSTEM WILL FUNCTION SATISFACTORY.
DATE .....:............................................... Inspector.............................. ......... .......... ...... ....