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App-Permit-Compliance
NO .. / .. THE COMMONWEALTH OF MASSACHUSETTS BOARD OF HEALTH .t..0...._....... 'L.) .......... OF .......... �../444.k-iMA.kAll....................................... Appliration for Disposal Works Tonstrarrtion thrmit Application is hereby made for a Permit to Construct (<) or Repair ( ) an Individual Sewage Disposal System at �'�.o1P lZ-1 ....... ........�':....... -4-.j ....:r'. ............ -- --- Location - Address O ne ---------------------••----•......... ...... G!!ll' . ............................... Type of Buildin Dwelling — o. of Bedrooms..............�-____._______.____. - - c va.'t `� 9 .. or Lot No. .........—....,,.,-�.:1:------- Address ...Expansion Attic aOther —Type of Building ............................ No. of persons ............................ Address Size Lot -_ �Z..©...Sq. feet Garbage Grinder ( ) Showers ( ) — Cafeteria ( ) P-4 Other fixtures .................................. W Design Flow ............................................ gallons per person per day. Total daily flow _._........_..!-t_4g;- ................ gallons. WSeptic Tank — Liquid capacity.1AP©..gallons Length ................ Width ............... . Diameter ................ Depth ................ x Disposal Trench - No . .................... Width .................... Total Length.. .................. Total leaching area .................... sq. ft. Seepage Pit No ------- I.......... Diameter.-Y?�!5___.... Depth below inlet--. - 15?........... Total leaching area.M3_.sq. ft. Z Other Distribution box 011") Dosin&tank ( )9 �r.. mPJ ........ Date... �- 1-4 Percolation Test Results Performed by.._ __.i.Sr.6.43 rill ..._! Test Pit No. 1..:<��._minutes per inch Depth of Test PitIZA: -......•-- Depth to ground water..fJP CLe...._. f= Test Pit No. 2................minutes per inch Depth of Test Pit .................... Depth to ground water ........................ � ....•d•••-----•----•--._....•••---•-•....._.-•--•----......••••-------.........----•-•------•--...------•-•-.....----•-------•--•---•-- Descriptionof Soil.. ..... .-lv» --aA"%d------------------------------------------------------------------------------------••---•-....--- --•----•------------------••-•---------•------ --•---•---...----------•---------•-•-•---•---•---•-----•-----------------------------•-----------•---•--•...._........---._....---•--•--•-------------•-- Nature of Repairs or Alterations — Answer when applicable................................................._..._...__............._...__..._.............. ............................................... ----------------------------------------••-••......._...---....----•----•-------•---••••-----------•-------•-----------•--•......---------......--••---- Agreement : The undersigned agrees to install the aforedescribed Individual Sewage Disposal System in accordance with the provisions of iITLZ 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 health. Signed Date d?-- sv� 7 Application Approved By. ............................................................... .......... .----.---- ---- Date Application Disapproved for the following reasons---------------•--•-----•------------------------------------.....-----------.............---•--•--•--...-•-••--- ......................•------------------...---------------------------------------.....---•--------...-- --•--•--.........------•---•--•-•-•-----•---•--------•-----•----•------•-------•--------------- Date PermitNo ......................................................... Issued ................... -----------•-•-----•-----------•--- Date THE COMMONWEALTH OF MASSACHUSETTS BOARD OF HEALTH .......................................... OF ..................................................................................... �i ifirtt�le of (�lant�r�i�tnrr --- THIS IS TO CERTI Y, hat ,,Individual Sewage Disposal System constructed ( '� or Repaired ( ) by-` - ............... ...................................................................................................... �- Irista ler at ,._ 1_/ -- .........----•--- :....c:? I r".. i-------------_------ 4he� 1------------------ has been installed in accordance with the provisions of TITLE 5 ofState Sanitary CP�e s de, ribed. in the application for Disposal Works Construction Permit No.___.�_ r "!_...._. dated___.._/_ _ pp THE ISSUANCE OF TO.11S CERTIFICATE Sh1AL1�'NOT BE CONSTRUE® AS A G ARA ~ EE THAT THE SYSTEM WILL FUNCTION SATISFACTORY. DATE................................................................................ Inspector