20 application and permit CHECK OR FILL IN WHERE APPLICABLE
No
.":........._.
THE COMMONWEALTH OF MASSACHUSETTS
BOARD OF HEALTH
OF
Application for Biopnmttl i r urko fkunstruriion Permit
Application is hereby made for a Permit to Construct ( ) or Repair ( ) an Individual Sewage Disposal
System at:
r.n
+wgra-Ana,,
?yner
et: ez
Installer
# Sr
or
Andras
Type of Building
Dwelling—No. of Bedrooms Expansion Attic
Other—Type of Building No. of persons
Other fixtures
Address
Size Lot.. Sq. feet
Garbage Grinder (k'V
Showers ( ) — Cafeteria ( )
Design Flow gallons
Septic Tank—Liquid capacity.lia,gallons
Disposal Trench—No Width
Seepage Pit No Diameter
Other Distribution box
Percolation Test Results
Test Pit No. 1
Test Pit No. 2
per person'per day. Total daily flow gallons.
Length Width Diameter Depth
Total Length Total leaching area y I- e sq.ft.
Depth below inlet-- Total leaching area sq. ft.
Dosing tank ( )
Performed by Date
minutes per inch Depth of Test Pit Depth to ground water
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 aforedescribed Individual Sewage Disposal System in accordance with
the provisions of Article XI of the State Sanitary Code The undersigned further agrees of to place the system in
operation until a Certificate of Compliance has been issued bythe board of health.
. /
Si ned ._i[. ..._,( /r7—..<%—' .v/,- . A .
y6,...7 '. : ts£r—rc`
Date
Application Approved By �.1 %..c• ht's ': '...a' ''u./.r, .a/ 02 .-
Application Disapproved for the following reasons'
Permit No
Issued
Date
Dale
by
mstHer
at ✓-c-I .11 !^ M r-.-u� o
THE COMMONWEALTH OF MASSACHUSETTS
BOARD OF HEALTH
Qlrrtifiratr of & hplinnrr
THIS IS TO CERTIFY, That the IndividuaCl4� ewage Disposal System constructed (V) or Repaired
442 J-.4., ,..r'7 _ .-t° � 7-4-dA '=A
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 j ' - dated r< ' c.v./!e.
THE ISSUANCE OF THIS CERTIFICATE SHALL NOT BE CONSTRUED AS A GUARANTEE THAT THE
SYSTEM WILL FUNCTION SATISFACTORY.
DATE' °- `r _ ' T Inspector
i
No i x
THE COMMONWEALTH OF MASSACHUSETTS
BOARD OF HEALTH
OF i L,r-t 44' IP
FEE
fispooxl rq orks kionutrution yrrmit
Permission is hereby granted
to Constrsuct Repair Repair ( ) an Indivi ual Sewage Disposal System
at No t `/ " T street
as shown on the application for Disposal Works Construction Permit No fOZ Dated '"tl'.;i�� .._6?1 F 11 6 L
DATE
e7-e I `r 2.4
FORM 1255 'Haase & WARREN. INC.. PUBLISHEAs
Board of HNIN