12 Applications & Permits CHECK OR FILL IN WHERE APPLICABLE
No t.*-
FEE '
THE COMMONWEALTH OF MASSACHUSETTS
Cr
t,cBOARD QF HEALTH
Op /� 0 _L f= G( L-,__.
Appliratinn fir Dispnzal Iltnrks Tons trnrtinn 1 rrmit
Application is hereby made for a Permit to Construct ( ) or Repair (x) an Individual Sewage Disposal
System at: 1
� _..Ml.�Li 1 ( C or Lot No.
LocA�`i�� 6tlP/(
�L
o. gr
44/44 Stet i
Installer
Type of Building
Dwelling—No. of Bedrooms
Other—Type of Building
Other . ..... ... .. .. .. ... ... s
Design Flow - .. _..��_ _gallons per person per day. Total daily flow
g5sT gallons.
Septic Tank—Liquid capacity L.7Crallons Lepgth Width Diameter Depth
Disposal Trench-No .-.... ... Width 3b Total Length co- Total leaching areaSS.2 sq. ft.
Seepage Pit No Diameter Depth below inlet Total leaching area sq. ft.
Other Distribution box ( ) Dosing tank ( ) i g /
,'/ Sce sdn /(
it Date /. Y l 1/
Percolation Test Results _ Performed by
Test Pit No. I ./..5. minutes per inch Depth of Test Pit a Depth to ground water /2-k e
Test Pit No. 2 minutes per inch Depth of Test Pit Depth to ground water
Description of Soil j4L.0
( S
3
I/O 7(a.arr.
Address L'
Size Lot Sq. feet
Expansion Attic ( ) Garbage Grinder ,(X)
No. of persons Showers ( ) — Cafeteria ( )
is-cc gC Zf-e`
C
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 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.
sr
57r e`
Application Approved By i
Application Disapproved for the following reasons
6e In
Permit No
Issued.
Date
ze
THE COMMONWEALTH OF MASSACHUSETTS
" BOARD OF HEALTH
' ( OF ('
C> rrtifiratr of Cumplianrr
THIS IS G (E17TIFY, That the-Individual Sewage Disposal System constructed ( ) or Repaired (X)
by
v I t q t I�semier
at /24 t
has been installed in accordance with the provisions of TITLE 5 of The State Sanitary Code as des ribed in the
application for Disposal Works Construction Permit No r -5 dated_ .,1i.�.-?j .7.�—
THE ISSUANCE OF THIS CERTIFICATE SHALL NOT BE CONSTRUED AS A GU RAN E THAVTHE
SYSTEM WILL FUNCTIOli SATISFACTORY.
i_
DATE /7 , {r%)_ Inspectorsdlt-: C "fi
No D l
THE COMMONWEALTH OF MASSACHUSETTS
BOARD OF HEALTH
OF ,,r,�.�-, w.-
3ispang arks.f rntn i dthn tirrmit
Permission is hereby granted -`.l( "tam
to Construct ` ) or (t r,K) Ind iyidual Sewage Disposal System
at No /9- "L E _At ke(
Street
as shown on the application for Disposal Works Construction Permi
DATE
i
FORM 1255 A. M. SULKIN. BOSTON
Board bt Health
CHECK OR FILL IN WHERE APPLICABLE
Firs
THE COMMONWEALTH OF MASSACHUSETTS
BOARD OF HEALTHJ G/fie OF / e/77,4.r t re i(/ yis
it
Appliratinn fur flispnsttl fl nrks Cnnnstrnrtiun Permit
tit .r ication is hereby made for a Permit to Construct ( ) or Repair ("Can Individual Sewage Disposal
System at: /
!4C/-lam Az97l,c/!//c-[.G /2 f711S �Z - ..flc /lAe--777" 1✓",)414/
Af./ w /9461 P%l eG /Ll%f T Y or Lnf!/r%
K> E ,
Address
IS/
Installer
Type of Building S422.4700.4i
___ - .,q. .�...
Dwelling— No. of Bedrooms Expansion ttic ((449 Garbage Grinder (AS
Other—Type of Building/( . .1 o. oftpersons (./ Showers (z) — Cafeteria (Ar
Other fixtures .. .alTTl/+G. re r
/p - / L.../ /1?,% s�
Design Flow //U gallons per person�peS day. Total daily flow//O Y3 X / gallons. Q9�
Septic Tank—Liquid capacit> elgallons Len$th``v // \Vidthr r.. Diameter_ Depth.
Disposal Trench--No. Width__. 1/� Total Length_._ Total leaching area_ sq. ft.
Seepage Pit No Diameter Depth below inlet_.*2_" Total leachin area. sq. ft
Other Distribution box ( /) Dosing tank j )�� /0n-7 d tiZ /�i r 8'/.Q-�$
Percolation Test Results Performed by �..4 .ern Date
91//e)/9.0"
Test Pit No. I tt °minutes per inch Depth of Test Pit.—„•%z rs Depth to ground water a0-41-04
Test Pit No. 2 nil tes per inch Depth of Test Pit Depth to ground water
z`,e ,,.-/ o a—ars .44rn......./.r-S.¢..... e°45 so/e-
Description of Soil 42/2"a ia-00 �5f Gam-¢ - Fl•---. .,$-!tN•b 57
Svctr S/7R/o fe -/Z/ ' Zec "S097 ci
ek0 �. /Z4o "
Nature of Repairs or Alterations Answer when a livable ---.tt7/2Z •jj�gp /(j/�
/t///// 6/2.1/40 711.5 t
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 issued by the board of health.
Signed X
Application Approved By
Date
Date
Application Disapproved for the following reasons.
Permit No
Issued
Date
by
THE COMMONWEALTH OF MASSACHUSETTS
BOARD OF HEALTH
OF
Qiertiftratr at (nmpliattrr
THIS IS TO CERTIFY, That the Individual Sewage Disposal System constructed ( ) or Repaired ( )
Installer
at
has been installed in accordance with the provisions of TITLE 5 of The State Sanitary 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
THE COMMONWEALTH OF MASSACHUSETTS
BOARD OF HEALTH
OF
No FEE
aiapuaal
I,
nrkn (Iktnnfrttrtiun j rrmtt
Permission is hereby granted
to Construct ( ) or Repair ( ) an Individual Sewage Disposal System
at No
Street
as shown on the application for Disposal Works Construction Permit No Dated
Board of Health
DATE
FORM 1255 A. M. SULK'S, BOSTON