77 Septic Application & Permit 1963 CHECK OR FILL IN WHERE APPLICABLE
No 7 FEE
THE COMMONWEALTH or MASSACHUSETTS
BOARD OF HEALTH
OF
)lpplirntian far J3ispnnat
r•r;
Application is hereby made for a Permit to Construct
System at:
i 1 0+ner p
k // stall rn�y,h
1 Installer
Type of Building
Dwelling—No. of Bedrooms Expansion Attic
Other—Type of Building No. of persons
Other fixtures
Design Flow gallons per person per day. Total daily flow gallons.
Septic Tank—Liquid capacity gallons Length Width Diameter Depth
Disposal Trench—No. Width 2i 1 Y d Q Total Length Total leaching area y 0 sq.ft.
Seepage Pit No Diameter Depth below inlet Total leaching area sq. ft.
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
arks Minstar-lion Permit
or Repair ( r) an Individual Sewage Disposal
or LM No.
Address
Address
Size Lot Sq. feet
Garbage Grinder ( )
Showers ( ) — Cafeteria ( )
Description of Soil
Nature of Repairs or Alterations—Answer when applicable
Agreement:
The undersigned agrees to install the aforedescrihed Individual Sewage Disposal System in accordance with
the provisions of Article XI of the State Sanitary Code-The undersigned fur er agrees not to place the system in
operation until a Certificate of Compliance has b een issded(7y;the board of h th.
Signed b .. : %c. . I / :94 . 11.4-1
Application Approved By
hitt
rye
Application Disapproved for the following reasons•
Permit No 4/ k
Date
issued _: � ...../..l_1k.�
Dais
by
at
has been installed in accordance with the provisions of Article XI of The State Sanitary Co as described in the
application for Disposal Works Construction Permit No ..9-. dated .4!: ..947.2n-/..
n-/..
THE ISSUANCE OF THIS CERTIFICATE SHALL NOT BE CONSTRUED AS A GUAR TEE THAT THE
SYSTEM W,N1 �FUNCTION SATISFACTORY.
.K,•.'. .---
DATE , :1'// 0 ) 2 Inspector..._ :..-1':`1...d.
U
THE COMMONWEALTH OF MASSACHUSETTS
BOARD OF HEALTH
(if. OF 11461'. y' [k�...p !
�rrfifirafie of Catpliana
THIS I TO CE TIFY, That the Individual Sewage Disposal System constructed ( ) or Repaired
/1) cfr
Installer
THE COMMONWEALTH OF MASSACHUSETTS
BOARD, vOF HEALTH
�j :� 't' OF.fefrt r;4, (ni
NO...1 FEE
Disposal mks (LConsfr iou Drrmif
Permisson is reby granted' ..i:L'' `j .'a 4 kCC s
to Construct (f or Repair L 8n Ind}vid(ial Sewage Disposal System
at No ,( 77...�y a'x. ,i: dC-
Street
as shown on the application for Disposal Works Construction Permit No L 01- Dated- I / Y!--3 Board Health
c I 2
DATE.74.447-di [ I k
FORM 1255 NeYes & WARREN. INC.. PUBLISHERS