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App-Permit-Compliance
Ut/K /f Nc '. No.8-Z5......... Fmc...$.1.5....00 THE COMMONWEALTH OF MASSACHUSETTS _ BOARD Off' HEALTH - ��?'7..........OF.......� lr>t"..................... Apphratiou for Bispag tl Works Tnnitrurtiun Vamit Application is hereby made for a Permit to Construct ( or Repair ( ) an Individual Sewage Disposal 4t' System at: _38 /.®-/� /aYNoe/Z �tc.. c%elle �Iryr mel � eL , r " ( (O f L 'on - Ad ess 5i ZU /WDrrI7 /�7C..lJy✓ i.. Owner Address W--•------------------'T.. .... 2INA........... ............................................. --•---••----------•-----•---------••------......---••-----------------•--•-•-••--------....._._... a Installer Address Type of Building Size Lot__24- 0.44'......Sq. feet U Dwelling — No. of Bedrooms ......... 4 .............................Expansion Attic ( ) Garbage GrinderPL4 ( ) Other — T e of Building No. of persons ............................ Showers ( ) — Cafeteria ( ) p•+ Other fixtures ....... ----_--------_ --•----•---•-------- W Design Flow............................................gallons per person per day. Total daily flow ............. 4+•-.57 ©................_gallons. WSeptic Tank — Liquid capacity/ gallons Length ................ Width ................ Diameter ................ Depth ................ x Disposal Trench — No. __----------------- Width .................... Total Length .................... Total leaching area -__-----------------sq. ft. Seepage Pit No... -__.1-_______-- Diameter____ �_. Depth below inlet.....L'........_.. Total leaching area.3-� 1__sq. ft. z Other Distribution box ()4) Dosing topj ( ) �. v�/e%res�--t21/e _ Date s� --' /g`%� Percolation Test Results Performed by_____________________•---__--------------------•-------•-•------- J - -----•---- aTest Pit No. 1. i Z._..minutes per inch Depth of Test Pit...,' —-_-__-- Depth to ground water ----- Xhd!?!_. Test Pit No: 2................minutes per inch Depth of Test Pit ---_-------------- Depth to ground water --____•___-------. -__- (x............................................•------------------------------------------------- ------------------- •----------------------------- D Description of Soil--- P® � ��...... �� `---------------s�_• _• or�------------------------------------•--------------------------...--- W-•-------•---------•--------------------------•--------•--------•---•-----------•-•----•--------•-------•-•-•--------------------------------•------•----•-•----•----•••......---•--. ------•----------- VNature of Repairs or Alterations — Answer when applicable ------------------------------- •------------------------------------------•---------------------------------------......------------------------------....------------.--------------------------------------------------------------- Agreement : The undersigned agrees to install the aforedescribed Individual Sewage Disposal System in accordance with therovisions of TITLE, p 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...................................................................................... - Y D'e, Application Approved BY--•------•----• _.................. Date ......... Application Disapproved for the fol owing reasons: ----------•------------•---------------•---•-•-------------------•--•-----•--------•----------•----------------- ........................................................... -................................................................. ....... -................................................................... Date PermitNo --------------------------------------------------------- Issued ....................................................... Date THE COMMONWEALTH OF MASSACHUSETTS BOARD OF HEALTH .......................................... OF ........................ ............................................................ (irdifiratr of T-nutpliattrr THIS IS TO CERTIFY, That the Individual Sewage Disposal System constructed (x ) or Repaired ( ) b J! --! P?l`�t. r -------------- --- Installer at........................................ — - --r'---- --- QEL---a 1i .---- -------- IO Tk ------------------------------------------------------------........--------------- has been installed in accordance with the provisions of TITLE j of The State Sanitary Code as described in the application for Disposal Works Construction Permit No --- ?":?a-------------------_-- dated__2� 1,1110. THE ISSUANCE OF THIS CERTIFICATE SHALL NOT BEC NSTRUED AS A GUARANTEE AT THE SYSTEM WILL FIKCTION SATISFACTORY. DATE--------- Z'5?Zz�.d-----•-----------------•------------- InsP