339 Application & Permit 1970 CHECK OR FILL IN WHERE APPLICABLE
No Li U Foo.;. . O D
THE COMMONWEALTH OF MASSACHUSETTS
BOARD OF HEALTH
tri OF / 1
Application for illispunal narks Olonstrn�rtiun lrrmit
Application is hereby made for a Permit to Construct ( ) or Repair (Y) an Individual Sewage Disposal
System at: a ��,�+/
.'� ..../.. .
Address or Lot No.
a
fr.
TYt/✓
Insmd7r Address
Type of Building Size Lot Sq. feet
Dwelling—No. of Bedrooms Expansion Attic ( ) Garbage Grinder ( )
Other—Type of Building No. of persons Showers ( ) — Cafeteria ( )
Other fixtures gallons
Design Flow gallons per person per day. Total daily flow ga
Septic Tank—Liquid capacity gallons Length Width Diameter Depth
Disposal Trench—No Width Total Length Total leaching area sq. ft.
Seepage Pit No Diameter Depth below inlet Total leaching area sq. ft.
Other Distribution box ( ) 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
Address
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 not to place the system in
operation until a Certificate of Compliance has been issued by the board of health
Signed. ..y.hf-/ +'•7 y/'�. %�j/..11f'.ij' .4(�te p
Application Approved By "'r"e--- yrxI ) r/ ..6.7.:4,c14.bb=l/ , n
Application Disapproved for the following reasons'
Permit No 11 0
Date
Issued. _ 7,..1.2.7 0
by
4 q (t F,I
at �� I 1. ��(C+u
has been installed in accordah e with the provisions of Article XI of The State Sanitary Code as described in the
application for Disposal Works Construction Permit No lit/ 92 i%
THE ISSUANCE OF THIS CERTIFICATE SHALL NOT BE CONSTRUED AS A GUARANTEE THAT THE
SYSTEM WILL FUNCTION SATISFACTORY. �(
DATE LC.-c..( .-17 % ( 74 Inspector.....;
THE COMMONWEALTH OF MASSACHUSETTS
BOARD OF HEALTH
_} ,
OF yer•7— too '.�. . . . .
rtifiratr of To liana
THIS,IS-T0 CERTsI,FY, That the Individual Sewage Disposal System constructed ( ) or Repaired (V)
Installer
No
THE COMMONWEALTH OF MASSACHUSETTS
BOARD OF HEALTH c
OF
IJis#IOnal orkn fdonstrurtinn Permit
Permission is hereby granted.. „r...,L.[=x
to Construct ( ) or Repair an Individtl�l �yage Disposal System
at No ::a�.Ea: ('�`
Street
as shown on the application for Disposal Works Construction Permit No /.6./ Dated �/
4-' t 2/-Boar of I ti(
DATE
FORM 1255 HOBBS & WARREN. INC.. PUBLISHERS