548 Application & Permit 1983 CHECK OR FILL IN WHERE APPLICABLE
THE COMMONWEALTH OF MASSACHUSETTS
BOARD, OF HEALTH
FEE
PgppWalliat fur Dinpnsttl Works Cfnnntrurt-um Permit
Application is hereby made for a Permit to Construct ( ) or Repair 0.4 an Individual Sewage Disposal
/ •
System at:
Qwner
... ICt va' '
Installer Address
a
Type of Building Size Lot Sq. feet
Dwelling—No. of Bedrooms. Expansion Attic ( ) Garbage Grinder ( )
Other—Type of Building fi� VCf No. of persons Showers ( ) — Cafeteria ( )
,£tcaroa,Address,
j
or:Lot No.
Address
Other fixtures
Design Flow
Septic T iguid capacity
Disposal No.
Seepage Pit No Diameter
Other Distribution box (t4
Percolation Test Results
Test Pit No. I
Test Pit No. 2
gallons per person per day. Total daily flow gallons.
gallons/`!Length Width..�--_�.__ Diameter Depth
Width....&&t Total Length A_5._... Total leaching area sq. ft.
Depth below inlet Total leaching area sq. ft.
Dosing tank ( )
Performed by J-h.- - '� Date Sys .rr..d
minutes per inch Depth of Test Pit Depth to ground water X..j
minutes per inch Depth of Test Pit Depth to ground water
C
Description of Soil
Ord "/
e
e.., ..L ij
Nature of Repairs or`Altdations—Apswer Lien applicable . 1
Cr
Agreement:
The undersigned agrees to install the aforedescribed Individual 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 issuedby the board of health.
Application Approved By
Signed
Application Disapproved for the following seaso
-}
i _ -2 /..t'�//ore
Permit No 9--73
Issued
Date
by
at
THE COMMONWEALTH OF MASSACHUSETTS
BOARD OF HEALTH
OF
ertifiratr of Qlumplittnre
tern constructed (/ r Re
THIS IS'Pb` ER IPY, t the•Individu Sex:lge Dis
lr
pBmstauer cat_
has been installed in accordance with the provisions of TITS 5 of The State Sanitary Code as d scribe the
application for Disposal Works Construction Permit No , — Q"3 dated 7� L_ `3
THE ISSUANCE OF THIS CERTIFICATE SHALL NOT BE CONSTRUED
SYSTEM WILL FON/CJ�j ON SATISFACTORY.
DATE �1.( % Inspector
A GUARA TEE THgr'THE
THE COMMONWEALTH OF MASSACHUSETTS
BOARD OF HEALTH
OF
FEE T.
313i0{Ino4L 3flarku QInustrurtin t rr_ttt t
Permission is hereby granted ` 1' —`t 1.
to Construct_( ,) or Repair (s--- an Individual Sewage Disposal System
as shown on the application for Disposal Street
at No J
sal �4'orks Construction Permit No 4,
TTT f c
DATE_._.....j.:_t 1_..i
FORM 1255 A. M. SULKIN, INC., BOSTON
‘,./Board of Health