127 Septic Application & Permit 1993 CHECK OR FILL IN WHERE APPLICABLE
;o. 3-93
THE COMMONWEALTH OF MASSACHUSETTS
/' BOARD OF HEALTH
CIT.� OF A442-7,409,4497-at)
» ppl ration for Disposal nrks Cionstrnrtion 1rrmit
Application is hereby made for a Permit to Construct ( ) or Repair an Individual Sewage Disposal
System at:
12 7 Coe14185 g'oAD
Loeattov
>4°rs... ll?IrB4.r.L
POwnt
I�T sn t ^!
Type of Building
Dwelling—No. of Bedrooms ...5— Expansion Attic ( ) Garbage Grinder (X)
Other—Type of Building No. of persons Showers ( ) — Cafeteria ( )
Other fixtures
Design Flow 67.6- gallons per person per day. Total daily flow sac gallons.
Septic Tank—Liquid capacity gallons Length Width 7... Diameter D th...
Disposal Trench—No._�._........ Width Total Length.../Oa Total leaching area... , .sq. ft.
Seepage Pit No Diameter Depth below inlet Total leaching area sq. ft.
Other Distribution box (7() Dosing tank )L
Percolation Test Results Performed by +T.:.A <..win e et,,. rS Date...%4./O ..i=
Test Pit No. I 2- minutes per inch Depth of Test Pit /O Depth to ground water
Test Pit No. 2 minutes per inch Depth of Test Pit Depth to ground water
c
Installer
or Lot Na
Address
Address
Size Lot Sq. feet
Description of Soil 4-V 3C-40.
/716A S's-!P /03"-no"
Nature of Repairs or Alterations—Answer when applicable
Agreement:
The undersigned agrees to install the aforedescribed Individual Sewage Di
the provisions of TITLE 5 of the State Sanitary Code—The undersigned further
operation until a Certificate of Compliance has been issued by the board of health.
Signed
Application Approved By
Application Disapproved for the folio
Permit No
Date
Issued
Date
THE COMMONWEALTH OF MASSACHUSETTS
BOARD OF HEALTH
OF trtifiratr of OQmuptia' t
thgl ividual Sewage Disposal System constructed ( ) or Repaired (2)
�7y
Instal
THIS IS T CE FY,
by ...f L.
at .:-J �tr✓X.:U9f`=/�.`-ii{'.z�../Y*=-cQ,rE`°"a S�"r-a."`
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 J'-.73 dated al;4/C9
THE ISSUANCE OF THIS CERTIFICATE SHALL NOT BE CONSTRUED AS A GUARANTEE THAT THE
SYSTEM WILL FUNCTION SATISFACTORY.
DATE. I-a- -� -S Inspector
No
THE COMMONWEALTH OF MASSACHUSETTS
BOARD� /OF� HE/�.LTH ,,._(/_,y_,_�
Cdi OF. /jr/ '�' 1
313 Disposal rh arks alonstrnrtion trmit
Permission is hereby granted
to Construct ( ) or Repair ( )
at No
as shown on n n
street
Saw
Z5 `
FEE
DATE
FORM 1255 U6o . n(dito C/5
5