666 Application & Permit 1991 CHECK OR FILL IN WHERE APPLICABLE
No
THE COMMONWEALTH OF MASSACHUSETTS
�t
BOARD OF HEALTH
C a y(... . OF_..NO eittaw+p4 on
FEB fro
_�� _
Application for Uispasal marks Ctanstrurtian '¥esanit t:-sR s.
Application is hereby made for a Permit to Construct ( ) or Repair (X) an Individual"tewagg`Dispof
System at:
iron-Address ` ' ,1 6G
N1rS4.T:1..._Y.f.A1 Address
CL-1 t.
Installer
Type of Building
Dwelling—No. of Bedrooms
Other—Type of Building No
2
Address
Size Lot.634.10 Sq. feet
Expansion Attic ( ) Garbage Grinder $ )
of persons Showers ( ) — Cafeteria ( )
Other fixtures
Design Flow .5.r r gallons per person per day. Total daily flow_2.2O.g.LS*33.0 gallons.
Septic Tank—Liquid capacity. 0. allons Length_%%' Width sr Diameter Depth...44'--
Disposal Trench—No Width Total Length Total leaching area 0 . sq. ft Sja.ty
Seepage Pit No I Diameter...3...i--T..- Depth below inlet....2,Q Total leaching area. . _
Other Distribution box ( ) Dosing tonli ( ) T
Percolation Test Results Performed by...f i CS Ektiave t.t«y..Ri.c. Date....31-..t7° S 4 PT!!
Test Pit No. I a. minutes per inch Depth of Test Pit g$ Depth to ground water.-Mt
Test Pit No. 2 minutes per inch Depth of Test Pit Depth to ground water
Description of Soil.._S40 4 a" bat-
Nature of Repairs or Alterations—Answer when applicable eft..00.C.aa+axv#' 0 t--.A R.0.1i
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 boar of health.
SignedYNiXD_- _
Application Approved By
Application Disapproved for the following reasons: _
Permit No.
3 '
Issued
if a- ft
THE COMMONWEALTH OF MASSACHUSETTS
(�
BOARD OF,L'HEALTH
`
4;` OF _.IVCLM.P..nn Tp
Certificate of Compliance
THIS IS TIF That the In 'dual Sewage Disposal System constructed ( ) or Repaired fX
ay 0-/LX JO t‘ 6 4_ F;cA.H.cl ev _r:-11 Fad Hc.
has been installe 'in accordance with the provisions of TITLE 5 of The State Environmental Code described in
the application for Disposal Works Construction Permit No. �J dated -//9/
THE ISSUANCE OF THIS CERTIFICATE SHALL NOT BE CONSTRUED AS A GUARAN EE THAT E
SYSTEM WILL FUNCTION SATISFACTORY.
DATE _P /�--✓.-`:1./
No
Inspector
THE COMMONWEALTH OF MASSACHUSETTS
BOARD OF HEALTH
. . .Cal �.... OF..J trT4`* MnP %Jh
Disposal I,inrks Otunntruutinn lrrmit.
Permission is hereby granted • •
to CoppstritFyt (, ) or Repair (A�t�) at}�I ividual Sewage Disposal System
at N42.b._1' 4--)..:4 tAn_KiAtt. K.A so-w<
as shown on the application for Disposal Works Construction Permit No
Dated..__.. _ _ ._. ..
y
✓�- Board of Health
DATE
' '
FORM 1255 HOBBS & WARREN, INC.. PUBLISHERS