255 Septic Application & Permit 1999 UiECK OR FILL IN%%HERE APPLICABLE
619
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THE COMMONWEALTH OF MASSACHUSETTS
BOARD OF HE/�ALTH
C27 or ll(ItYl<Lr.({•IL [yN
Appliratinu fnr Biannual i!Qnrks Qinnsirurtinn Paint
Application is hereby made for a Permit to Construct ( ) or Repair (X) an Individual Sewage Disposal
System at:
256 C'ler h7orj m. R )
�,,'
tanwa•Anna
6ae. —i1.4r r'.,e,, 7_
o...,
Of Mt NA
-J-:saw wee....
Type of Building
size La. 4n Of90t' Cq, (¢[
Dwelling— No. of Bedrooms.. �{-)cr a ._Expansion Attic ( ) Garbage Grinder (N)
Other—Type of Building ..._._.—._.._.. No. of persons.... _... Showers ( ) — Cafeteria ( )
Other futures
Design Flow.--6.5—..._...._.__,.gallons per person per day. Total daily flow_ .'SC ,�—___gallcuss
Septic Tatb— !_iquid apaciry%.'.i.2..gulluns LengthZQ.L_.. Width$___.... Diameter.._ thSf_& /
Disposal Talakig— No. 1.-... Width )7' _...Total Length..9-O .Total lathing area YCQ.q. ft.
Seepage Pi[ No Diameter..........._._.... Depth below inlet_ . Total leaching area __..__sq. ft.
)
Other Distribution box ( Dosing pkik (I) qq /
Percolation Test Results Performed by .ez.2ezuz t /r m G(*. Date 422_7. �
minutes per inch Depth of Test Pit..g. .. Depth to 4 t
Tea Pit No. 1 < cap ground water
Test Pit N u. 2..._.....__.minutes per inch Depth of Test Pit..—_—_.. Depth to ground water _
Description of Soil...._..........aaLtir2� .PcNTD
Nature of Repairs or Almruiuns—Answer when applicable �Lr RTr1.3L.htF�._.��z4�r
Agreement:
The undersigned agrees to install the aforedescribed Individual Sewage Disposal System in accordance with
the prorisiou. of TITLE 5 of the State Sanitary Code— The undersigned further agrees not to place the system in
operation until a Certificate of Compliance has ban sawed byy the boar t pf health.
Signebte.
Application Approved By......._.._....._...._._......._._._..—
Application Disapproved for the following reasons.
Permit No....—. Iacu,.t
Ova
Dom
THE COMMONWEALTH OF MASSACHUSETTS
BOARD OF LTH
{ OF
/r
Llrrtif irafr of Canny nrr
by.
THIS 1.} TO lij'jT)NThat t Individual . 7t.gi is Sy;tsn constructed ( ) or Repaired (1)
aL-_ %AS.S Q k5
has been installed in accordance with the provisions of IT7r99�ii``5c a State Sanitary Cottle ) deee77 d in the
application tor Disposal Works Construction Permit No TS...� T dated /f fO —7
THE ISSUANCE OF THIS CERTIFICATE SHALL NOT BE COMET E S A GUARANTF6-Ty(¢T THE
SYSTEM WIL F{�NQTON TISFACTORY.
DA:` I CC"'� • �'/%D Z 1 _ er-_a.
.^-.p -_
THE COMMONWEALTH OF MASSACHUSETTS
BOARD OFfj H LTH
OF ceVti
ftapu9a1 If�Arlili Qlnuxiirurtihn fIrrmlf
gmatm..—.-_---�--2 C-dN(✓C92
Permission is hereby
to Construct -) RC�sr (X) - + lndiv'dtul S aee Disposal Sysrmt
ar No.— C6 Ci - /E'.�,r
a�
as shown an the application for Disposal Works Construction Permii��`gf7/
I1/iS/f,
3a
Fns_ �a
DATE_
Date
MA.a M $ a
'S wn... ...t.. 1.1.r.u.14117.