574 Applications & Permits CHECK OR FILL IN WHERE APPLICABLE
THE COMMONWEALTH OF MASSACHUSETTS
BOARD OF HEALTH
Faa T�.0 u—��r�
O
C i -/ OF NA r+La,.1... p.Lir.1 :oj!�
Applirtttinit fur 3lispuSttt rgnrks Tunstrurtinn P nl}t
Application is hereby made for a Permit to Construct (.'or Repair ( ) an Individual-$e gge, Dis
FR'_DE
System at:
KeYMedy R.d
,C3J114 n�prd:: Olt o
Owner
C�flt3
�6. '.I.....5.Q!-1i=Lels.1.1-1—j_4Y✓1 tje
Address
Installer
Type of Building
Dwelling— No. of Bedrooms Expansion Attic
Other—Type of Building No. of persons
Other fixtures_ .
Design Flow .55 L..X • 5 gallons per person per day. Total daily flow (nine gallons.
Septic Tank—Liquid capacity/SOO gallons Length..(..S Width 5, __. Diameter —" Depth-5• 3
Disposal Trench—No. .3 Width 22 U • Total Length 2 01'0 Total leaching area...f/.Q.ZcCsq. R.8c{�ew-,
Seepage Pit No -- Diameter �— Depth below inlet 2, O Total leaching area 8 aid sq. ft.Std
Other Distribution box (I/5 Dosing t 'lj _( ) .
Percolation Test Results Performed b .- i./_ll CS... cr" I't-c-S Inc /10-- ....:2,6
y. .. �1�l.� f1 r p Date_ 23
Test Pit No. 1__/..S minutes per inch Depth of Test Pit (01 Depth to ground water.../1..8"
Test Pit No. 2 minutees per inch Depth of Test Pit ,LC Depth to ground water /20 r
Description of Soil....L.1.7.7.G.C.i1�L1
Address
Size Lot_2Z1.232:4j7.Sq. feet
Garbage Grinder (ye
Showers ( ) — Cafeteria ( )
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 TITLE 5 of the State Environmental 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
Application Approved By
Application Disapproved for the following reasons:
Dace
Date
are
Permit No. Issued
as
THE COMMONWEALTH OF MASSACHUSETTS
BOARD OF HEALTH
L rl..`L. OF NC r41.Cowt.f7SO'Ll
Certificate of Compliance
THIS IS TO CERTIFY, That the Individual Sewage Disposal System constructed O( ) or Repaired ( )
by
at .iot #3tiertia P4
has been installed in accordance with the provisions of TITLE 5 of The State Environmental Code as described in
the application for Disposal Works Construction Permit No. dated
THE ISSUANCE OF THIS CERTIFICATE SHALL NOT BE CONSTRUED AS A GUARANTEE THAT THE
SYSTEM WILL FUNCTION SATISFACTORY.
DATE Inspector
No
THE COMMONWEALTH OF MASSACHUSETTS
BOARD OF HEALTH
' OF Ai c r+Li°Ann p)(
flinnrniat olorkg &nutria/inn Prrutit
Permission is hereby granted Ti C Lk)
Fesces
to Construct ()C ) or Repair ( ) an IncliArirl Sewage Disposal System
at No. Li.c 3„ curlled. lg.
Street
as shown on the application for Disposal Works Construction Pep N
DATE Lt-c- 3 (93
1255 @HAND Hoses WARPEN TM Publishers
Datte2,-F 3
Board of Health