Lot 14 Title 5 Application/Permits 1995 1;;;; !a r
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CHECK OR FILL IN WHERE APPLICABLE
fS-
THE COMMONWEALTH OF MASSACHUSETTS
BOARD OF HEALTH
OF
Application fur Binomial
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Application is hereby made for a Permit to Construct ( ) or Repair k) an Individual
System at:
Type of Building
Dwelling—No. of Bedrooms �? Expansion Attic
Other—Type of Building
Other fixtures
Design Flow
Septic Tank—Liquid capacity
Disposal Trench—No
Seepage Pit No
Other Distribution box
Percolation Test Results
Test Pit No. I
Test Pit No. 2
No. of persons
Ions per person per day. Tot
ons Length Width
Width Total Length
Diameter Depth below inlet
Description of Soil
Address
Address
Size Lot Sq. feet
Garbage Grinder K )
Showers ( ) — Cafeteria ( )
Total daily f flow 473- gallons.
Diameter Depth
Total leaching area sq. ft.
Total leaching area_ sq. ft.
Dosing tank ( )
Performed by Date
minutes per inch Depth of Test Pit Depth to ground water
minutes per inch Depth of Test Pit Depth to ground water
Na re of e rs or Alte ' ' s—'Af swer when
A�reement: /
The undersigned agrees to install the aforedescribed Individual Sewage Disposal System
the provisions of TITLE 5 of the State Sanitary Code—The undersigned further agrees not to
operation until a Certificate of Compliance has been issued by t - boar. of health.
Application Approved By
Application Disapproved for the following reasons
in accordance with
place the system in
4
Date
Permit No
Issued.
1 „ (l
D
,Fs rA
CHECK OR FILL IN WHERE APPLICABLE
THE COMMONWEALTH OF MASSACHUSETTS
BOARD OF HEALTH
OF'
Appl ration for Uisptsttl
Application is hereby made for a Permit to Construct
System at:
Type of Building
Dwelling—No. of Bedrooms
Other—Type of Building
Other fixtures
Design Flow
Septic Tank—Liquid capacity/ ��al
Disposal Trench—No. Width
Seepage Pit No Diameter
Dosing tank ( )
Performed by
minutes per inch Depth of Test Pit
minutes per inch Depth of Test Pit
arks @tonstrnrtinn Permit
or Repair k) an Individual Sewage Disposal
,Lai.../..! ..._................_..._..._.._.._.._._.
or Lot No.
Address
Address
Size Lot Sq.yfeet A
Expansion Attic ( ) Garbage Grinder )
No. of persons Showers ( ) — Cafeteria ( )
Ions per person per day. Total daily flow 975-
gallons.
Ions Length Width Diameter Depth
Total Length Total leaching area sq. ft.
Depth below inlet Total leaching area.. sq. ft.
Other Distribution box
Percolation Test Results
Test Pit No. 1
Test Pit No. 2
Description of Soil
Data
Depth to ground water
Depth to ground water
A eement:
The undersigned agrees to install the aforedescribed Individual Sewage Disposal System in accordance with
the provisions of TITLE S 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 t - board of health. a//yyl�
Application Approved By
Application Disapproved for the following reasons
Permit No
Date
Issued
THIS
by
at q
has been installed in accordance i h the provisions •f TT The S The State Sanitary Coda as de bed in the
application for Disposal Works Construction Permit No L9.. dated '7/JO �5r�'3
THE ISSUANCE OF THIS CERTIFICATE SHALL NOT BE COPJ;TRU AS A GU EE THAT THE
THE COMMONWEALTH OF MASSACHUSETTS
OARD OF HEALTH
�y OF
fQertifirate of aiuntpl tur U/
dividual Sewage Disposal System constructed ( ) or Repaired
CE
SYSTEM WI FUNCTION SATI5FAC ORY.
DATE 1f(W"�' 7I, I Inspector
THE COMMONWEALTH OF MASSACHUSETTS
OARD OI HEALT
�I . OF
fli.pa at orb
Permission is hereby granted
R
to C onstruct
at No
as shown on the
DATE
•
r a Individ Via• /sposall S si elA�
i so-�m /�
application for Disposal \ orks Construction Permit No...
FORM 1255
A/A-0-6v 1x55_
BOSTON
FS
Board of H