Lot 4-A Title 5 Application/Permits 1971 CHECK OR FILL IN WHERE APPLICABLE
No Fsa
THE COMMONWEALTH OF MASSACHUSETTS
e ���/// BOARD OF� T-
HEALTH t a
Application for Disposal r:arks elonstrnrtiun f rani#
Application is hereby made for a Permit to Construct ( or Repair ( ) an Individual Sewage Disposal
System at p, Sr- Lvnt- 4 ft
1
M1.AAdr
0
Installer
crti
. z&
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 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 sq. ft.
Seepage Pit No Diameter Depth below inlet Total leaching area sq. ft.
Other Distribution box ( ) Dos' ( ) `
Percolation Test Results Performed b .. .. .... .. . .. Date 1 z`' '
Test Pit No. 1 5— minutes per inch Depth of Test Pit vjn D th to ground water-F( .`
Test Pit No. 2 minutes per inch Depth of Test Pit ,1-2.11
� Depth to ground water
Descrip 'on of Soil lam.. .... .—K -4=0=11$4...... ..1..14-iL?ny
Nature of Repairs or Alterations—Answer when applicable
Agreement:
The undersigned agrees to install the aforedescribed Individual Sewage Disposal System in with
the provisions of Article XI of the State Sanitary Code—The undersigned further agrees not to e s
operation until a Certificate of Compliance has been issued by the board of health.
Signed
Application Approved By k- .t..9%f. -n.ri
Application Disapproved for the following reasons• .41114t/
Permit No Issued
Date
by
THE COMMONWEALTH OF MASSACHUSETTS
BOARD OF HEALTH
OF
aitrtifiratt of Tamp liana
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 BE CONSTRUED AS A GUARANTEE THAT THE
SYSTEM WILL FUNCTION SATISFACTORY.
DATE Inspector
No
THE COMMONWEALTH OF MASSACHUSETTS
BOARD OF HEALTH
OF • / -
/1
Disposal e nrIto Mansirtirlion Wroth
Permission ereby granted 4
to Const ( ) or Repair ( ) an Individual eSewage Disposal'System
atNo
Street
/
as shown on the application for Disposal Works Constructio,a,ermit No Dated ll.'
DATE -‘4 {^tE 1 0 (i7/
FORM 1255 HOBBS & WARREN. INC., PUBLISHERS
Marl of Filth
CHECK OR FILL IN WHERE APPLICABLE
No li> 4 In/ G C
THE COMMONWEALTH OF MASSACHUSETTS
BOARD 9F HEALTH
{{
�
GL) OF 1`'C d �trfl
Appl ratinn for 1ispusal i,ork9 QInnmrurtion lrrmit
Application is hereby made for a Permit to Construct
System at:
±i -1-c cYA
(OG: LL t, „c
or Repair ( ) an Individual Sewage Disposal
Type of Building
Dwelling—No. of Bedrooms
Other—Type of Building
Other fixtures
Design Flow � gallons per person per day. Total daily flow gallons.
Septic Tank—Liquid capacityty.+.5 gallons Length Width Diameter Depth
Disposal Trench--No. Width Total Length Total leaching area .g22.Qsq. 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. 1 ..5 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
or Lot No.
Address
ddress
Address
Size Lot Sq. feet
Expansion Attic ( ) Garbage Grinder (.1
No. of persons Showers ( ) — Cafeteria ( )
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 board of health.
Signed
Application Approved By - a:G1-s£t- L1.....iTa.tE.0 .l_G /97/
C,
Application Disapproved for the following reasons
Permit No /. -.. ...... ..
11 Da te
Issued TtL.&.[—J 6 IQ/
6