565 Septic Application & Permit 1962'HERE APPLICABLE
CHECK OR FILL IN
No
THE COMMONWEALTH OF MASSACHUSETTS
BOARD OF HEALTH
OF
Application for In ood II orb; Oionntrurtion ljermit
Application is hereby made for a Permit to Construct ()0 or Repair ( ) an Individual Sewage Disposal
System at:
.>d- 61040 Jleder c17a,,
Lion rs s. ‘4" 21Lee,10-tr
`
u Installer Address
Type of Building Size Lot Sq. feet
Dwelling—No. of Bedrooms a Expansion Attic ( ) Garbage Grinder ( )
Other—Type of Building No of persons Showers ( ) — Cafeteria ( )
Other fixtures
Design Flow gallons per person per day. Total daily flow gallons.
Septic Tank—Liquid capac)ty644..gallons Len h Width ,J/�� Diameter Depth
Disposal Trench—No. / Width al 0•..t. Total Length..24 AI' Total leaching area b Q_d.sq.ft.
Seepage Pit No Diameter Depth below inlet Total leaching area sq. ft.
Other Distribution box (✓j 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
Description of Soil
Nature of Repairs or Alterations—Answer when applicable
Agreement
The undersigned agrees to install the aforedeseribed Individual Sewage Disposal System in accordance with
the provisions of Article XI of the State Sanitary Cale--The undersigned further agrees i of to place the system in
operation until a Certificate of Compliance has issued the oa d of h th.
� ._.
Application Approved By 3 t
Due
Application Disapproved for the following reasons
Permit No `S
Issued
Date
{r /962
THE COMMONWEALTH OF MASSACHUSETTS
BOARD OF HEALTH
OF col
ertifirxtt of fin liana
THIS/S,TO CERT�Y-, That tle Individual Sewage Disposal System constructed ((/) or Repaired (
y,
A-tY i') '
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 3 dated. la Lk.1.I.k a--
THE ISSUANCE OF THIS CERTIFICATE SHALL NOT BE CONSTRUED AS A ARANTEE THAT THE
SYSTEM WILL FUNCTION SATISFACTORY.
DATE._. w`fc_./._j�..;..y b a
Inspector.
.)1- ;' nti-ran
THE COMMONWEALTH OF MASSACHUSETTS
BOARD /OF HEALTH
.4 t* OF y07"-tita
No Q FEE
Tisposnl.�/i�__����nt[rkn QIr(tatrurtinn tirrmit
Permission isJhereby granted Yic+.W``//}} T a.tlAC....eV.
to Construct Vj or Repaii (, ) An IndividuafSewage Disposal System
at No ,z n.4 /lr::. .1YAaP w-\didlsi
Street
as shown on the application for Disposal Works Construction Permit No...a Dated. /if;2—
DATEc. tr• - i� l`1�
FORM 1255 HO(,S & WARREN. INC.. PUBLISHER,