Lot 3-A Title 5 Application/Permits 1969 CHECK OR FILL IN WHERE APPLICABLE
No.3..7..%_.......
THE COMMONWEALTH OF MASSACHUSETTS
FES
yBOARDOF HEALTH
C(C'y ......OF /%q'(
Appliratinn for Oispnsal rc nrks &instruction Permit
Application is hereby made for a Permit to Construct (Vc or Repair ( ) an Indic idual Sewage Disposal
System at:
`212,(4 s.r n L i 4-
-3 A
T Location\rylecss ., or Lot No.
OwoetiN 4.taiL 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 .5 d gallons per person per day. Total daily flow gallons.
Septic Tank—Liquid capacity%Q.tDgallons Length Width Diameter Depth
Disposal Trench--No. Width Total Length Total leaching area sq. ft.
Seepage Pit No Diameter.._ .@ Depth below ivlet.2y Total leaching area sq. ft.
Other Distribution box ( ) Dosing tank ( ) f-C6 --b2erQt 5 t.,.2z'r
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 aforedescrihed Individual Sewage Disposal System in accordance with
the provisions of Article XI of the State Sanitary Code— The undersi'ned further agrees not to place the system in
operation until a Certificate of Compliance has been issued by the boa d
Application Approved By 4.?>:.W�L 3. ._6c.4..K. c. 2-941 u Date
Application Disapproved for the fonowing reasons.
Permit No...3 7
pp Date
Issued ! 'a 9..9.6.
Date
THE COMMONWEALTH OF MASSACHUSETTS
BOARD OF HHEALTH
(... M OF. "7: 4.14-CRAt1t{F..tj
Qrnrtifirtttr of Cuholionrr
THIS IS TO CFIRTIFY_That the Individual Sewage Disposal System constructed ( ) or Repaired ( )
by
m.mu
/; .r
at.has been installed in accordance with the provisions of Article XI of The State Sanitary Coyle as described in the
application for Disposal Works Construction Permit No ,:. dated .rL'%4- 1 /e/E7
THE ISSUANCE OF THIS CERTIFICATE SHALL NOT BE CONSTRUED AS A GUARANTEE THAT THE
SYSTEM WILL FUNCTION SATISFACTORY.
DATE Inspector s..a�._ rL ..71£iw"a•'?
THE COMMONWEALTH OF MASSACHUSETTS
BOARD OF HEALTH
OF
FEZ
Thnpnsttl ki.nrko Qtnnntrurfinn lrrmit
Permission is hereby granted
to Construct ( r5 or Repair ( ) an Individual Sewagej)isposal System
at No
So-.«
as shown on the application for Disposal Works Construction Permit No Dated
Board of Health
DATE
FORM 1255 HOBBB & WARREN. INC.. PUBLISHERS
HERE APPLICABLE
CHECK OR FILL I
No Fee
THE COMMONWEALTH OF MASSACHUSETTS
BOARD OF HEALTH
Fl OF ,U0K77/114-1o77,0
Application for 3lispusal I O urks totrttrtiun tirrmit
ton is hereby made for a Permit to Construct ( 1.) o/r Repair ( ) an India idual
Sewage-age Disposal
System at
1.1f}i2:1_DA ) Si GL; f 3 p-
....3:a. L I tief-
Owner
Lstaller
Nor EDJu&tsr ' V--
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 Beath below Fnlet Total leaching area sq. ft.
Other Distribution box
Percolation Test Results
Test Pit No. 1
Test Pit No. 2
Dosi
Performed by
minutes per inch
minutes per inch
. Date._ :—.02d R_-_
epth of Test Pit �ttpth to ground waterrz__
Depth of Test Pit Depth to ground water
Descriptio of Soil (}' .... L.A..r2�.._ .... ..
Nature of Repairs or Alterations—Answer when applicable
Agreement:
The undersigned agrees to install the aforedescribed Individual Sewage Disposal System it
the provisions of Article XI of the State Sanitary Code— The undersigned further agrees not to la' th
OC g ` `t 1
operation until a Certificate of Compliance has been issued by the board of health.
Signed
Application Approved By
Application Disapproved for the following reasons'
VI JP/ Opn
'w424
�sS1
Permit No
Date
Issued
Daze