105 Title 5 Application/Permits 1990 1W-13
CHECK OR FILL IN WHERE APPLICABLE
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THE COMMONWEALTH OF MASSACHUSETTS
BOARD OF HEALTH �j�/J
c -)3 OF ,4&Acy-A ,,s9 ...i� / -
urks Tonstrurtion rrmit
Oration fur Disposal
Aiication is hereby made for a Permit to Construct ( ) or Repair (dean Individual Sewage Disposal /
System at - - -- - ; /yl.9:Q ' cOrt/ .e, - Viee. 7// /f 144/
,fl4 /DsetJ 5? %`v Ala Mtn"-
5/(L Jam[. yAdd[e
gxr=a
bas A rtaa
Type of Building ,_3/," q.+o Siz Lot feet
Dwelling—No. of Bedrooms�j�.._`....... Expansion Attic ( Garbage Grinder ( S
Other—Type of Building�s -- / .-- No of rsons Showers (z) — Cafeteria wo
Other fixtures eff /7OGr 6/4, V/raf'/ agfaZell A
Design Flow .17‘) ga ons per �e en per day. Total daily flow..//Q`..3'"/SV gallons.T9S
Septic Tank—Liquid rapacio0 g5 iteti.CLength Width • �.... Diameter Depth
Disposal Trench—No. ..,3--.... Width ....Up' Total Length and Total leaching area.. aq. ft.
Seepage Pit No Diameter Depth below inlet/a otal leaching area ��. f F%a
Other Distribution box (/) Dosing tank ( ) _in-ne m /474.•• _ eS/age
Percolation Test Results Performed by_, C. LCL.t.& !! J '42tee Date 40.740/.9.3..
Test Pit No. 1Gt7'O minutes per inch Depth of Test Pit Tee " Depth to ground water..Q4"
Test Pit No. 2 ,77-:',inutes per inch Depth of Test Pit Deppth to ground water O SUB
Description of Soil 2.9 —7/ Ccgrt° s r . NO 7/— �y C..-" 0
p a 4' e c7' //z0 ne..✓•
77)1, -t- u/szirccd Ay 60*' /f,04,sr J;(1, i`____
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 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 i�uedby the boajA f health.
Signed
Application Approved By
Application Disapproved for the following reasons'
Permit No
Date
Date
Date
Issued.
THE COMMONWEALTH OF MASSACHUSETTS
OARD OF HEALTH
ertifirate of Tomplianre
THIS IS TO C TIF ha
by . —
at t v✓
has been installed in accordance with the provisions of TITrr �o e State Sanitary Co o as scpibed�±n
application for Disposal Works Construction Permit No L Q ' dated [! F
THE ISSUANCE QF THIS CERTIFICATE SHALL NOT BE CONSTR JED S =UARANT/,Tl THE
dividual Sewage Disposal System constructed
or Repaired l yy
SYSTEM WILL FU ION SA SFOR �
DATE 111-- ------
No_.�
Inspector
THE COMMONWEALTH OF MASSACHUSETTS
BOARD AO�F HEA TH
OF / if 1 U t44 '� -41^
mispnbat �M new Olnnstrnrtiun Permit
Permission is hereby granted " C) aTn._cy r
to Construct ( ) or Repair N ) an Individual Sewage Disposal System
0
at No �1. 5 � r1
s.r
`P �z
FEE- ^n
as shown on the application for Disposal Works Construction Permit No.1d/I—L.. Fated
/ T - BoL re of eelth
DATE