Misc. Lot 4 Septic Application & Permit CHECK OR FILL IN WHERE APPLICABLE
Fax
THE COMMONWEALTH OF MASSACHUSETTS
BOAR
C:r9 T;a ar' n1
OF
iratian fur %punat marks CIlnnntrurtinn thrmit
Appl cation is hereby made for a Permit to Construct ( ) or Repair ( ) an Individual Sewage Disposal
System at:actis f�it1 Oci. go
e 0? ' :/!/anonnri,s•
trci
A.
or Lot No.
Address
Installer 1/4....) Address DTI/ ,c KG�
Type of Building s Size Lot Sq.
Dwelling—No. of Bedro T. rLt...F40..} Expansiotjrattic ( ) Garbage Grinder ( )
Other—Type of Buildine= No of persons Showers ( ) — Cafeteria ( )
Other fixtCt� �. -�
Design Flow `a ,50Jgallons per person E day. Total gs Mow mere.
Septic Tank—Liquid capa* gallons Width .--.Length Width a Diameter Depth '''
Disposal Trench—No. idth Total Length .30
Total leaching area If. 1- ft.
Seepage Pit No Diameter Depth below inlet Total leaching area sq. ft.
Other Distribution box ( ) Do ) �p�
Percolation Test Results Performed by flak'a % i—16t`jN') N Date 5-I-71
Test Pit No. I.. a., minutes per inch Depth of Test Pit.___.. t... Depth to ground water
Test Pit No. 2 a— minutes per inch Depth of Test Pit .... Depth to ground water "
8o ''
Description of Soil O5 SS�Ic Cafir Silu
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 Cod e.�, The under 'gned further agrees not to place the system in
operation until a Certificate of Compliance has been /rd of health.
Application Approved By
Application Disapproved for the following reasons
Permit No
Date
Issued
by
THE COMMONWEALTH OF MASSACHUSETTS
BOARD OF HEALTH
OF
@lrrtifiratr of Tnmplttmrr
THIS IS TO CERTIFY, That the Individual Sewage Disposal System constructed ( ) or Repaired
Installer
at
has been installed in accordance with the provisions of TITLE 5 of The State Sanitary Code as described in the
application for Disposal Works Construction Permit No
THE ISSUANCE OF THIS CERTIFICATE SHALL NOT BE CONSTRUED AS A GUARANTEE THAT THE
SYSTEM WILL FUNCTION SATISFACTORY.
dated
DATE Inspector
THE COMMONWEALTH OF MASSACHUSETTS
ink)V jo/S S —
0 BOARD OF HE LT
% O OF 44 p'
No 7 .
/44)
Bison F nrkn nnntr ttinri r it
Permission is hereby granted ' C � e t)� ° S m
to Construct (Y)LaFThRegeir ( ) n ndi4id�aad Sewage osal System
at No (�. tr6 -F-QJL �_'Yt.@n be s
Street
as shown on the application for Disposal Works Construction Permit
DATE
dntw~ 3t �l1 / 5
FORM 1255 A. M. SULKIN, BOSTON
Fez
of Health
ss