12 Title 5 Application/Permits 1967 IN WHERE APPLICABLE
CHECK OR
}3 Ess
THE COMMONWEALTH OF MASSACHUSETTS
BOARD OF HEALTH
.4
OF ; ;, rl-P
Appliratinn far Bthpunal Harks Qtunstrurfinn 1 rrmit
Application is hexeby
System at , 64.
4
de for a Permit Construct ( ) or Repair
.:
anL�
Installer
) an Individual Sewage Disposal
or Lot No.
Address
Address
Type of Building Size Lot Sq. feet
Dwelling—No. of Bedrooms Expansion ( ) Garbage Grinder ( )
Other—Type of Building No. of persons Showers ( ) — Cafeteria ( )
Other fixtures re� .. cc
Design Flow •.JL:{!.
tgallons
Septic Tank—Liquid capacity_- -Oxgallons
Disposal Trench—loo. Width
Seepage Pit No ( Diameter
per person per day. Total daily flow
Length Width Diameter Depth
Total Length Total leaching area sq. ft.
Depth below inlet Total leaching area 74 sq. ft.
33 0 A gallons.
Other Distribution box (
Percolation Test Results
Test Pit No. 1
'rest Pit No. 2
Dosing tank„(; )
Performed by
minutes per inch
minutes per inch Depth of Test Pit
Date
Depth to ground water
Depth to ground water
Depth of Test Pit
Description of Soil
Nature of Repairs or Alterations—Answer when applicable
Agreement:
The undersigned agrees to install the aforedescrihed Individual Sewage Disposal System in accordance with
the provisions of Article XI 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
Application Approved By Sc_ [!' "``.� f' '�a't"`i•��'O7
date
Application Disapproved for the foliovring reasons•
Permit No - ` l
Issued. / N'4 j / Y
hat
Date
2
THE COMMONWEALTH OF MASSACHUSETTS
BOARD OF HEALTH
l.;t.-. oF. /�cnL?sm" QI
ertifirer of Tamp inure
THIS IS T -CERTIFY, That tt�,e Individual Sewage Disposal System constructed ( ' ) or Repaired ( )
a- 4 fret
by 't/ /
4 smm�rl
has been installed in accordance with the provisions of Article XI of The State Sanitary Code as descried in the
apphaui-n for Disposal Works Construction Permit No .['..r_f.-5 dated—?Jtr* .2_Liit7
THE ISSUANCE OF THIS CERTIFICATE SHALL NOT BE CONSTRUED AS A GUARANTEE THAT THE
SYSTEM WILL FUNCTION SATISFACTORY.
DATE •44.t.+r,-Y '161 Inspector.._;
No xy3
THE COMMONWEALTH OF MASSACHUSETTS
BOARD OF HEALTH
� OF._._!��Twjr e
Qispnsttl parks QCnnstrpctinn Permit
Permission fs ereby granted
Construct ( or R 'r (,
FEE
to C ) an Individual ew e Disposal System
at No
as shown on the application for Disposal Works Construction Permit No :+ %
(/
Boar fHea10
,pated
DATE
FORM 1255 HOBBS & WARREN, INC.. PUBLISHERS
jhr. 1 !!47