Lot 3-B Title 5 Application/Permits 1971 CHECK OR FILL IN WHERE APPLICABLE
No...:/ 5 /
THE COMMONWEALTH OF MASSACHUSETTS
BOARD OF HEALTH
h1y _ of 1., f:LaJ:n
Auuliration fur32ts}fosttt Pork Cnutuitrurtion Prrmit
Application is hereby made for a Permit to Construct (✓) or Repair ( ) an Individual Sewage Disposal
System at:
11/14÷L A 313
L2oo Lot No.
,Lx( ow„n i.L6/
4
Installer
f{( '1.4t
n�scane.
Type of Building
Dwelling—No. of Bedrooms Expansion Attic
Other—Type of Building No. of persons
Other fixtures
Aadtet,
Size Lot Sq. feet
Garbage Grinder
Showers ( ) — Cafeteria
Design Flow /'gallons per person per day. Total daily
Septic Tank--Liquid capacit .4gallons Length Width
Disposal Trench--No. Width Total Length
Seepage Pit No Diameter Depth below inlet
Dosing tank ( )
Performed by
iinutes per inch Depth of Test Pit
minutes per inch Depth of Test Pit
flow gallons.
Diameter Depth
Total leaching area d Qsq. ft.
Total leaching area sq. ft.
Other Distribution box
Percolation Test Results
Test Pit No. 1
Test Pit No. 2
Date
Depth to ground water
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 NI 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 tRe board of health.
iii 6 ' * �
Application Approved B y c J i£ % rL%iv 1 r/ 1 �
.L1 7�d us
;
Application Disapproved for the following reasons
Permit No 1 )
Oatt
by.
WARD OF HEALTH
OF
Trrtifiratt of Tomptiatur
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
e
No —1
Permission
to Construct
at No...............
as shown on the
THE COMMONWEALTH OF MASSACHUSETTS
BOARD OF HEALTH
'..c1' OF .P
o
(1/41
Elispoottl. 'Pi arks alottotrurtiott tlerinft
is
reby granted •t We-4
or Repair ( an Individual Swage Disposal Sy em
34j g
Street c.
application for Disposal Works Construction Fersnit No .t7 te Dated
t
Board
DATE
FORM 1255 HOBBS & WARREN. INC.. PUBLISHERS
ECK OR FILL IN WHERE APPLICABLE
No
THE COMMONWEALTH OF MASSACHUSETTS
BOARD OF HEALTH
G/ TY. . ... OF WoeZi4,17a°70.04........
Application for 1 hipunnl Wnrlw (IIottntrnrtintt ilrrntit
Application is hereby made for a Permit to Construct ( ) or Repair ( ) an Indhaduai Sewage Disposal
System at:
, ASziel.dl -
_ Lwaliar-Address or Lot No.
P. CtC/, 4��ri N s ' N "it 4.1
Owner Address
Installer Address
Type of Building Size Lot 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 ( ) Dosing tank ( )
Percolation Test Results Performed by✓HART — P104.71—e-Y E ti!~.' Date 43 -rb 7/
Test Pit No. 1 0- '3 minutes per inch Depth of Test Pit_, "-0" Depth f• ground water._.eL..P &-
Test Pit No. 2 minutes per inch Depth of Test Pit...4 --1<" Depth to ground water_.it`- i*I
Description of Soil 0 = 4" rypsc'c.-,. i'-G ",5iz r/ S"WO 3-2" A74/c .eta -13ge..'eJ
.F,1 n/0
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.
unee
Date
Dam
Application Approved By
Application Disapproved for the following reasons
Permit No
Issued
Date