Lot 4-B Title 5 Application/Permits 1971 IECK OR FILL IN WHERE APPLICABLE
THE COMMONWEALTH OF MASSACHUSETTS
Fox A.-5
{BOARD 'tOF HEALTH
L x- OF 9{9'..e/ } SY
Applirntiun fur finpunn! nrann(IIunntrnrtinn 1 rrmit
Application is hereby made for a Permit to Construct
System at: , 1
._.........._.._..__...7/1/4-1-ca : :.C..t1.._ -
Lorvum ad.ess
Gd
or Repair ( ) an Indic idual Sewage Disposal
T
Address
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 _ per person per day. Total daily flow gallons.
Septic Tank-Liquid capacity" 5 .gallons Length Width Diameter Depth
Disposal Trench—No. Width Total Length Total leaching area ,-Q4..sq. ft.
Seepage Pit No Diameter Depth below inlet Total leaching area sq. ft.
Other Distribution box ( ) Dosing tank ( )
Percolation Test Results Performed by Date
Test Pit No. I 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 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 bo d of health.
i
SiKned t,G(j2 <` 6,,c4E.1'/ �L.t
Application Approved By <ip y'C1-:C...C% LLz�:�G. ;. � X-up6."�"f7,/
11 D
Application Disapproved for the following reasons'
Permit No.._H.14G' C
Data /
Issued...`<1f:: [e; •tFr_.`.1f---7f-
by
THE COMMONWEALTH OF MASSACHUSETTS
BOARD OF HEALTH
OF
Qtrthfiratt at Qtmntp(iaitn
THIS IS TO CERTIFY, That the Individual Sewage Disposal System constructed ( ) or Repaired
Installer
at
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 dated
THE ISSUANCE OF THIS CERTIFICATE SHALL NOT SE CONSTRUED AS A GUARANTEE THAT THE
SYSTEM WILL FUNCTION SATISFACTORY.
DATE Inspector
No
THE COMMONWEALTH OF MASSACHUSETTS
WARD OF HEALTH
Bigwig*, Arlw Cnnstrurttinn jrrmit
Permission t reby granted...._.;°_..!!!til.�
to Construes_,( or Repair ( ^) an Individual Seyvage Disposal System
at No ithei.,ddd!! j r r 1
Street as shown on the application for Disposal Works Construction Permit No'if q Dated _s 1,40.4■.
Board e h �i -'
Fzsl.,:i 0
DATE
FORM 1255 HOBBS R WARREN. INC.. PUBLISHERS
CHECK OR FILL IN WHERE APPLICABLE
No Fite
THE COMMONWEALTH or MASSACHUSETTS
BOARD OF HEALTH
(/7/ OF.... !UCl.E'T..YAA7,areA/
Application for Iliaposal IIYtorku Ton trllrtioll Permit
Application is hereby made for a Permit to Construct (y) or Repair ( ) an Lobe idu:d Suwag
System at:
Cec/Ce C�i�K.aaar�
Owner
*13
Disposal
or Lot No.
!I€elfAa SWCCT
Address
Installer Address
Type of Building Size Lot id:52J0 '± 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 capacity gallons Length Width Diameter Depth
Disposal Trench—No. Width Total Length Total leaching area
q. ft
Seepage Pit No
Other Distribution box ( )
Percolation Test Results
Test Pit No. 1 �'3.
Test Pit No. 2
Diameter Depth below inlet Total leaching area
Dosing tank ( )
Performed by,Zs/ ..$&RQE9a " wt[LEy....E.tti&Gtt Date 1/45/7/
minutes per inch Depth of Test Pit 2'5"/ Depth to ground water 'Awe
minutes per inch Depth of Test Pit c'0" Depth to ground water ,AA'NE
q. ft.
Description of Soil
4" ra 5o'/ 4'-'f' ge49c'y sq v1•
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 Xl 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
Application Disapproved for the following reasons'
Date
Date
Date
Permit No Issued
Date