Lot 20 Septic Application & Permit t
CHECK OR FILL IN WHERE APPLICABLE
Fxx._.m..
THE COMMONWEALTH OF MASSACHUSETTS
BOARD OF HEALTH �,/�/
dry OF N®.eW///-� .41
Oration for Uisposttl Marko Cnonstrurfion tirrntit
on is hereby made for a Permit to Construct ) or Repair ( ) an Individual Sewage Disposal
s.--SSW' #vetoyvtav: $ rFr,"
Owner Address
Installer s
Address
Type of Building
c �
�.Q j Size Lot_S!!.)/ q. feet
Dwelling— No. of Bedroom9.� �l Expansion fp ttic (�4 Garbage Grinder (xj
Other—Type of Building/ y460 :. of persons (� Showers (� — Cafeteria 4-4
Other fixtures �rllfG! G�'u.G
ures .
,....,.s.. . ..,....�...r.... ..a_.._.._ per
yy_...rI�r gallons. 4%S
Septic Tank—Liquid capaci gallons Length..er. Width • Diameter Depthr
Disposal Trench—No....at. Width..JGre Total Length_... Total leaching area sq. ft.
Seepage Pit No Diameter Depth below inlet-.. ....ft Total leaching area if ft L
Other Distribution box (n Dosing tank ( )ad ,,, ern L s,a' J/�/� le/
Percolation Test Results Performed byy� .j.p`t� ,jh/.r'�3'je�o�,R. 199 /90
Test Pit No. I.. /.?minutes per incl_�Depth of Test Pit 476.. Depth to ground water —
Test Pit No. 2 Unifies per inch�D,re�pth o.f,'Test Pit Depth to ground water
.. / �7/l�la py. &.roes 5�[..t//G 540-1V,C...L</='y
Description of•Soil. ,he I/LG ,se " %t L.rZ OzeY....a' t 1r&a... r 96
saw. S2.to Lere..«4v4CN tJ r3_...O -Z.. .l°.Sr'a ?.-eta rL-s Scott
coo t.?y
tx:t-/J!lrr.Y Cyr. �4f/c/ i.�.r"/ �.•./6? .?"/1,u0�/
Nature ofReep`airs or�AA.lterat ions—Anno swer when applicable / ,04"W 4 1.[$ — XAiI-fr Q-'. 7LcfJ
Agreement: ',-.i ®- ' GvS et,l �' ,.-,ir..Yy..Tio
The undersigned agrees to install the aforedescribed Individual Sewage Dl os em afFo rrtecv
the provisions of TITLE 5 of the State Sanitary Code—The undersigned further agrees not to place the systettyy'tL ` J
operation until a Certificate of Compliance has been issued by the board of health. /Oj•7 c'�_i"s/O+/.�
Sigr�ed..4z •1-27“.4y1-..-1.:7-- i %# r'�% F/q0
_ Hale SiY.(i/f
Application Approved By - - i- - f'
p
Date 4,40/6,6
Application Disapproved for the following reasons'
Data
Permit No Issued.
THE COMMONWEALTH OF MASSACHUSETTS
BOARD OF HEALTH��
OF t
(QPrtifiratf of Clontplianaa
THIS IS ��QQ)%6ERTIF hat the Ina: idual Sewage Disposal System constructed (v or Repaired ( )
by (!YI!1!ti.....
C6 p-41 a
at
has been installed in accordance with the provisions of TITLE 5 of The State Sanitary Code as describ in the
application for Disposal Works Construction Permit No dated
THE ISSUANCE OF THIS SFTICATE SHALL NOT BE CONSTRJIFD(p GUARANTEE THAT THE
SYSTEM WILL FU TION SATISFACTORY. enc2,0— ,
�O c0 DATE ! Inspect or
THE COMMONWEALTH OF MASSACHUSETTS
BOARD OF HEALTH I
OF
No
Disposal
iF
arks (Construction Vrrmit
FEE —
Permission is hereby granted
to Construct OC) .or Repair ( ) an Individual Sewage Disposal System
at No
street . -_.
as shown on the application for Disposal Works Construction Permit No Dated..
t
Board of Health
DATE
FORM 1255 A. M. SULK IN. BOSTON