5 Application & Permit 1992 CHECK OR FILL IN WHERE APPLICABLE
THE COMMONWEALTH OF MASSACHUSETTS
BOARD OF HEALTH
c% ..- G'TI OF. /1/4:€77/722/3#1 ,C1 ,41,ss-S
ppliratinn fur Disposal ft urks Qtunstrurtinn 'ljrrntit
on is kter.eb ade f Permit tp _Construct (x) or Repair ( ) an Individual Sewage Disposal
J_ f .d6c /vveY2/79ti-/,onn',c _-I, '
Vvtl �.0 �,A 47 S Le, & !kip,` ' Installer Address C'.L�4 /,�
�/B,�/. rica4-7 Size Lot /'a'�J r/ Sq. et
Type of el Building- Y' � �y Garbage Grinder �y0
Dwelling- No. of Bedrooms persons.e Attic we, g (7T
Showers - Cafeteria GOO
Other- f B "ld ��� No of persons� (�
Type o ur lug _ .-- Cat-
Other �Yl�
p` day. dad flow/l
r fixtures Ions per . .. . _..._1d2/T _. ...._.._ 1 . Y/,mil gatlonsbee0
Design Flow /10 gallons per oer ay.
/j� �� Width._ - Diameter Depth..'..
Disposal Tank-Liquid raZi lWidt- t:" Tot Total leaching area sq. ft.
D" sal Trench-ti o W"dth.3iO�� Total Length .P�� n8
Total leaching u
Seepage Pit No
po
Uiameter Depth below inlet./ T eac in area
Dosing tank ( ) ,S0//�N) ZSZ .CyZg_ v/0-405" �� �
Other Distribution box (� ) g �-/«( Date ���T/S/''//
Percolation Test Results Performed by "X/P1.1../7 Tes "/-f' '°�� y
Test Pit No. 1 2" O minutes per inch Depth of Test Pit Dept "ttrgro¢rtd water
minutes per inch Depth of Test Pit Depth to ground water
C1/75-. a-- L9 soes0/C
...,//Ltd-1 -,11Cla...5'C�%2C/ 7Z -//¢
5/L—' _ ,440- 7Z-n. O ax a..s---
Nature of Repairs or Alterations-Answer when applicable
Test Pit No. 2
Description of Soil
The undersigned agrees to install the aforedescribed Individual Sewage Disposal System in accordance with
Agreement:
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.
Application Approved By
Application Disapproved for the following reaso
d.
Permit No
Issued_
Date
by
THE COMMONWEALTH OF MASSACHUSETTS
cit BOARD OF HEA TH
OF A)
fternfirntr of (Cnmpli re
TH[S l TGn CER I V. That the I d,fdual Sewage Disposal System constructed (X) or Repaired ( )
1 r V rl$,tG nnanu
at .s _.._ ...
i
has been ins ailed i acco dance with the sions of TITL5 of he State Sanitary Code as describAd in the
application for Disposal Works Construction Permit No 7-
.2-- dated_& 4)—a ' )--
THE ISSUANCE OF THIS CERTIFICATE SHALL NOT BE CO TRUED AS,4 GUARANT;E THAT THE
SYSTEM WILL FUJIC'JION SATISFACTORY. dll�/J
DATE /0/// F4 Inspector
No 74$.
THE COMMONWEALTH OF MASSACHUSETTS
BOARD OF HEALTH
of .. AbleriA mnviv. ..
lily
3r i led ,p�& vshow ttirttyttnt rrmA
Permission he�rebby granted Individual
at Nonst sr eeCte-('�IMF' AryVP ewag��P R Systemwvs,A/Atie, L//Pp an
at No snu _qz ze_fe
as shown on the application for Disposal Works Construct'
SW—
DATE
FORM 1255 A. M. SULKIN, BOSTON