404 Septic Application & Permit 1992 -
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CHECK OR FILL IN WHERE APPLICABLE
Fizz
THE COMMONWEALTH OF MASSACHUSETTS
/ BOARD /OAF HEALTH
Applirntion for Blotto OOE arks &t instruction 1 trmit
Application is hereby made for a Permit to Construct ( ) or Repair (?O an Indhidual Sewage Disposal
System at:
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._tZa.geneck.7.j--..Se 5
Installer
Type of Building
Dwelling— No. of Bedrooms 3 Expansion Attic (
Other—Type of Building No. of persons
or Lot No.
Address
Ayemi 04A2?„.-.e.roK2 ei/—a-%)
Address
Size Lot Sq. feet
Garbage Grinder (-()
Showers ( ) — Cafeteria ( )
Other fixtures .5"
gallons.
Design Flow 55— gallons per person per day. Total daily flow
Septic —Liquid capacity ns Length Width Diameter D ep th
Disposal Trench—No. 4. Width3 otal Length 4FTotal leaching area l5.,1
D
Seepage Pit No Diameter Depth below inlet Total leaching area
Other Distribution box (•x) Dosing tank ( ) ground 41-28 7pZ
//�� /` C/ 7C Date...
Percolation Test Results Performed by -5.-h '+-7+ � p
Test Pit No. 1._` minutes per inch Depth of Test Pit Depth to water
Test Pit No. 2 minutes per inch Depth of Test Pit Depth to ground wat _ ....-_.
Description of Soil Al?, tie A:$44r Stbsed.?i .'�-jL'T % �oy to -&
sq. ft.
q. ft.
Nature of Repairs or Alterations—Answer when applicable
Agreement:
The undersigned agrees to install the aforedescribed Individual Sewage
the provisions of TITLE 5 of the State Sanitary Code—The undersign°-
operation until a Certificate of Compliance ha issued by the rdd eat
Signed
Application Approved By
Application Disapproved for the following reasons'
Disposal System in ac
her agrees not to place the system in
th.
742/4 ....
/aft/5_a--
Permit No
Issued.
Date
6
THE COMMONWEALTH OF MASSACHUSETTS
BOARD OFF HEALTiH
OF Ai
Tvrtifirati.of Tomplia �
he ual Sewage Disposal System constructed ( ) or Repaired
(MA..s1a29&
/// _idescyibed in
A RANNTiTTEE TTHATTHE,Lj q cJJe5* c�i le
at
I been installed in accordance with the provisions of TISLEQQ 5 of The State Sanitary o
application for Disposal Works Construction Permit Nio..v�(y
THE ISSUANCE OF THIS CERTIFICATE SHALL NOT BE CONSTRUES AS
—SYSTEM }
WIL UN TION SATISFACTORY.
DATE .---�-
(? ( Inspecto
5L
No
THE COMMONWEALTH OF MASSSACHHUSETTS
BOARD E y e-d"
OF
flispnM4 Ws QItyti nutu! n Frrmit
x a ¢ osal System ieect4—'1.4
Board of Health
PnstUct oq js�hereby.pr
to Construct �t (Pl
at No
as shown on the
Fe Z0 rs
Street
ication fo Disposal`orks Construction Permit No.
DATE
FORM 1255 A. M. SULKIN, BOSTON