68 Septic Application & Permit 1971 No...Ve j3
THE COMMONWEALTH OF MASSACHUSETTS
BOARD OF HEALTH
7.
At
Appliratiun iur 3iupusttl rr arks QTun,wiruriiun 3rrmit
Application is hereby made for a Permit to Construct ( ) or Repair (‹an Individual Sewage Disposal
System at:
r ,
(14L,.1_
y+ra' i L Ad
pp��n on ddry4 or Lot No.
owner (
p� !
Address
W.1 <.../.2"<.../.2":“A-4 4 et Y*.,... :t..,AW. ::.)lnJiler
Address
Type of Building Size Lot Sq. feet
Dwelling—No. of Bedrooms Expansion Attic ( ) Garbage Grinder ( )
WOther—Type of Building No. of persons Showers ( ) — Cafeteria ( )
1't' Other fixtures
C
al Design Flow 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 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
CHECK OR FILL IN W
Description of Soil
Nature of Repairs or Alterations—Answer when app licable...:2_4Lq{24.tMR.._.:.
•
404
Agreement:
The undersigned agrees to install the aforedescribed Individual Sewage Disposal System in accordance with
the provisions of Article XI of the State Sanitary Code— The undersigned further agrees not to place the system in
operation until a Certificate of Compliance has been issued by the-board of health.
Signed . • z.......: 'c.,lK .r
... 4ate�
Application Approved By .. l a..< _?aeS.a!s( r..l.... /satC...� ..._%.L./...
Date
Application Disapproved for the following reasons
Permit No /
Date
Issued. 71.cY.._!_1 L1J
Date
by
THE COMMONWEALTH OF MASSACHUSETTS
BOARD OF HEALTH
OF
trrtifiratr of Tamolianrr
THIS IS TO CERTIFY, That the Individual Sewage Disposal System constructed ( ) or Repaired ( )
Installer
at
has been installed in accordance with the provisions of Article XI 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.
DATE Inspector
No.`"/1....p
Permission
to Construct (
at No
THE COMMONWEALTH OF MASSACHUSETTS
BOARD OF HEALTH
OF
ij
FEEr
Disposal. arks (IInustruttiun irrmit
is hereby granted. s..;` Ya+.:F ..:.::rr.,z-".4G
or Repair (t' ) an Individual Sewage Disposal System
rriatLat
Street
as shown on the application for Disposal Works Construction Permit ..... Dated
DATE
FORM 1255 HOSES & WARREN
NC.. PUBLISHERS
,,is l..d �.
Hoard of H ith.
l j Jl