Lot 5-B Title 5 Application/Permits 1970 CHECK OR FILL IN WHERE APPLICABLE
No 34e
THE COMMONWEALTH OF MASSACHUSETTS
BOARD OF HEALTH
OF .ed—airgiffelq
Apptiratirftt far fah posal �i Strurtiun lrrtttit
Fex
Application is hereby made for a Permit to Construct (f )� or Repair ( ) an Individual Sewage Disposal
System at: `5.6
O ,td or Lot No.
• pwn�t Address
L�lZ.`'�D.'i'IDxlsllet Address
Type of Building Size Lot Sq. feet
Dwelling—No. of Bedrooms Expansion Attic ( ) Garbage Grinder ( )
Other—Type of Building No of persons Showers ( ) — Cafeteria ( )
Other fixtures
Design Flow gallons per person per day. Total daily flow gallons.
Septic Tank—Liquid capacittnal gallons Length Width Diameter Depth
Disposal Trench—No. Width Total Length Total leaching area sq. ft.
Seepage Pit No i Diameter Depth below inlet Total leaching area.J a sq. ft.
Other Distribution box ( ) Dosing tank ( ) Ater-tail a'
Percolation Test Results Performed by Date
Test Pit No. 1 minutes per inch Depth of Test Pit Depth to ground water
Test Pit No. 2 minutes per inch Depth of Test Pit Depth to ground water
Description of Soil
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 Article X1 of the State Sanitary Code—The undersigned further agrees not to place the system in
operation until a Certificate of Compliance has b issued by the board of healt
Signed ..�e n`6�—rF!yY`rtif
It Plenn 427 97
Application Disapproved for the following reasons'
Application Approved By
`' .. .. ._..... ___._ .. n 91oat
Permit No3l. 4 Issued 1. LO
THE COMMONWEALTH OF MASSACHUSETTS
BOARD OF HEALTH
;licv-TrLorkrjraz
airrtifirati at Tamp liana
THIS IS TO CERTIFY, That the Individual Sewage Disposal System constructed (V5 or Repaired ( )
by ,44A1.adai .2441-Quir
Installer
at tre-s t<, 'o t•-• ' - ...1 t—
a ,is
has been installed in accordance with the provisions of Article XI of The State Sanitary Code as described in the
application for Disposal Works Construction Permit No i 2.4 dated
THE ISSUANCE OF THIS CERTIFICATE SHALL NOT BE CONSTRUED AS A GUARANTEE THAT THE
SYSTEM WILL FUNCTION SATISFACTORY.
4.1.44-4,- .es./ 4:1-2,
DATE
THE COMMONWEALTH OF MASSACHUSETTS
BOARD OF HEALTH
.
EiCt
Elisposat, IH arks clianatrurtion tirratit
Permission whereby granted t1 4, 4 al -4-4-7,-/-1-4,14-
to Construct (, or Repair ( ) an Individual S
at No ' f?
•
FEE
age Disposal System
Street
as shown on the application for Disposal Works Construction PecmR No ' iDaled "i‘i K.'7
.e • -41A.
t /1 Boardalleald
DATE
FORM 1255 HOBBS & WARREN. INC.. PUBLISHERS
CHECK OR FILL IN WHERE AP
No
THE COMMONWEALTH OF MASSACHUSETTS
BOAR
OF
Applirnti t for 3Uiopoenl
Application is hereby made for a Permit to Construct
System at: J -
SR '—
Q r c!L L o- L
Installer
Type of Building
Dwelling—No. of Bedrooms
Other—Type of Building No. of persons gi.
Other fixtures ✓GG.4r_•Yt —
Design Flow gallons per person per day. Total daily
Septic Tank—Liquid capacity gallons Length Width
Disposal Trench —No Width Total Lengt
Seepage Pit No Diameter B. th belo
Other Distribution box ( ) Dos' )
Percolation Test Res is Performed by
Test Pit No. 1_.. minutes per inch
Test Pit No. 2 minutes per inch
arks
Firs
nnatrurtinn Permit
or Repair ( ) an Indir idual Sewage Disposal
��� Address
Addles.
Size Lot Sq. feet
,.� Expansion Attic Garbage Grinder ((n.r)
Showers ( f) — Cafeteriakt4
flow gallons.
Diameter Depth
Total leaching area sq. ft.
Total leaching area sq. ft.
/e a
y� r�_.. Date._ '—'Z Jam 7O
pth of Test a t 'r.8 '— --: th to ground water--x.a—v—e,
Depth of Test P t II pth to ground water
Description of Soil...Avg. w..i-ei t....-.':ice.@...at# RRX. °i- a -ta ./tQ.QtJ..iJ i Oa
V t. ...
Nature of Repairs or Alt Alterations—Answer when applicable
Agreement:
The undersigned agrees to install the aforedescribed 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
Date
Date
Date
Application Approved By
Application Disapproved for the following reasons•
Permit No
Issued
Date