358 Septic Application 1973 WHERE APPLICABLE
CHECK OR EIL
No....�L' J�
THE COMMONWEALTH OF MASSACHUSETTS
jB. OARDaOF HEALTH
OF /)OiStin1
Attitliratinn far fis}msttl Narks (llnnstrurtion Vaunt
Application is hereby made fora Permit to Construct ( ) or Repair (!i xn lnditidual Sewage Disposal
System at:
-Loe -Addars t or Lot Do.
Installer
Type of Building
Dwelling—No. of Bedrooms
Other—Type of Building
Other fixtures
Design Plow gallons per person per day. Total daily flow gallons.
Septic Tank—Liquid capacity gallons Length Width _ . Diameter Depth
Disposal Trench—No. Width Total Length Total leaching area al. ft.
Seepage Pit No Diameter Depth below inlet Total teaching area sq. fl.
Other Distribution box ( ) Dosing tank ( )
Percolation Test Results Performed by - Date
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
Address
Address
Size Lot Sq. feet
Expansion Attic ( ) Garbage Grinder ( )
of person Showers ( ) — Cafeteria ( )
No
Description of Soi
Nature of Repairs or Alterations—Answer when applicable Odd i ' -goal
II
Agreement: .
The undersigned agrees to install the aforedescribed Individual Sewage Disposal System l r accordance with
the provisions of Article NI of the State Sanitary Code—The undersigned further agrees not to place the system in
operation until a Certificate of Compliance has been issued b the board of health.
Signif? -fa-li
c s Yr`°t
Application Approved By :,.y"@Pf 3._.c't.# i G.tQ� �tN + -.t
DDe
Application Disapproved for the following reasons'
Permit No
63
Issued Lev
Date
THE COMMONWEALTH OF MASSACHUSETTS
BOARD OF HEALTH
OF.
rrtifiratr of To liana
THIS iS TO C RT FY That the Individual Sewage Disposal System constructed ( ) or Repaired ( )
Iaela'
at .,s._lt GR4„-� 'rd all
has heen installed in accordance with the provisions of Article NI 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. ��� "
Y 91 Inspector_
u(. ( / 3 a�- . __ .. .� 44tl
No 03
THE COMMONWEALTH OF MASSACHUSETTS
BOARD OF HEALTH
Litt, _ of _ jdiL +fi
FEE S. 06
Di,posrJ„ii3orka 03uny��{p�i'frrurtion iirrmit
Permission is hereby granted/ l..-411-a-Ji
to Constrnctj ) LLor Rely n Individual Sewage Disposal System
at No J-rr--4L16yt_. °y Street ermit No KC -5 Dated_-item / i
as shown on the application for Disposal Works Construction
DATE
FORM 1255 HOSES & WARREN. INC_ PUBLISHERS
Hoard of HeI6