20 application and permit 1994 ECK OR FILL IN WHERE APPLICABLE
THE COMMONWEALTH OF MASSACHUSETTS
'r'
BOARD OA�F��//HEALTH
C/i7 OF N0/[/r,/tr Tiv
Appl ration for 33ispimal nrk5 Qlvnntrurtinn Permit
Application is hereby made for a Permit to Construct ( ) d .. &C an Individual Sewage Disposal
System at:
/t/L+i
ion-Address / or Lot No.
S7vtd >r'.._EM,u.c/ MAC-4C 3.L... .e nt1.& eitai
Owner Ad ress
Cuff LLBR.K.. Lvl.t.Li.FkM 1'a.✓C (s
Installer Address
Type of Building Size Lot.z20 0 o d Sq. feet
Dwelling—No. of Bedrooms 3 / Expansion Attic ( ) Garbage Grinder ( )
Other—Type of Buildin g SJaa6 .Y I.. No. of p ersons Showers ) — Cafeteria ( )
Other fixtures
Design Flow Yc'r gallons per person per day. Total daily flow yf../..5-- gallons.
Septic Tank—Liquid capacity gallons Length Width Diameter Diameter Death
Disposal Trench—No. ea_._-__ Width 3 Total Length'/ / Total leaching area Lif..a.f2sq. ft.
Seepage Pit No Diameter Depth below inlet Total leaching area. sq. ft.
Other Distribution box (. f Dosing tank ( ) n/ I
Percolation Test Results Performed by 'tZ L+» 1/ /nfi-A .v.P' =- Date ..2/4.7/4
Test Pit No. I minutes per inch Dept hh of lest Pit Depth to ground water
Test Pit No. 2 minutes per inch Depth of Test Pit Depth to ground water
Description of Soil 6U .e"/° t SLinl C l j
Nature of Repairs or Alterations—Answer whe applicable g
f4.. ...... /-11.(14,/:(-
Agreement: /
The undersigned agrees to install the aforedescribed ndividual Sewage Disposal System in accordance with
the provisions 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 been issued by the board of health.
Sig�edF'
Application Approved By � � lr 1,4 �
Date
Application Disapproved for the following reasons
Date
Permit No Issued
Due
by
at 3.1
THE COMMONWEALTH OF MASSACHUSETTS
BOARD OF HEAI4TH
firafe of Qlomplia
THI TO C That e Individual Sewage Disposal System constructed ( ) or Repaired (y/
W
Installer
has been installed in accordance with�e provision of TIT5 of The Late Sanitary Code a descri ed in the
application for Disposal Works Construction Permit No « — 7� dated 7{v'il.
THE ISSUANCE OF THIS CERTIFICATE SHALL NOT BE CONSTRUED AS A GUARANTEE THAT THE
SYSTEM WILL ON SATISFACT RY.
DATE j Y
13. ../ 1.4
......_....._.. Inspector [...4.L,L'.Y !/wt.�f9'�"'
TH COMMONWEALTH OF MASSACHUSETTS
r 4 BOARD QDIF HEAIrtH
OF
No FEE
Ilis}Tns 1 wanrka Cian rurtian tirrtnit,
. , , r IL/
Permission is hereby granted " t' � -
to Construct L )_ or Repair ,t` )_a�t Individual Sgwage Disposal System
at No 1 C
as shown on the application for Disposal Works Construction PermitMNo_:.. " " ,Dated �/= 2/1-
„ y Board of Health
DATE
FORM 1255 A, M. SVLKIN, BOSTON