Lot 1-A Title 5 Application/Permits 1968 IN WHERE APPLICABLE
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THE COMMONWEALTH OF MASSACHUSETTS
FEE
BOARD OF HEALTH
C 4 / OF_kit,y_ 11 A.Fl pre
Application for ?3isposal Pnrtts Oluuntrurtinn Vrrmit
Application is hereby made for a Permit to Construct (14-411- Repair ( ) an Indio idual Sewage Disposal
System at:
........._M..(.T..1``:l_l'.'.�- S I �C ♦-" /AL
CC.LI Gfl
4Jx?.:...01 17 C= ruts,
Address
Installer 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 . e '( ) t.44_____(t p
Percolation Test Results Performed by 2i..;.s(L41.. Vn Date_ —2 S —�O
Test Pit No. 1 Z minutes per inch !N[_ .
Test Pit No. 2 minutes per inch
Depth of Test Pit
Depth of Test Pit
epth to ground wa er.____ .
Depth to ground water
Description of Soil_ .f: .. -
S.-axe .__.4.i - C )4
)1 - a. :h.&
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 placer(he g1s .rn in
operation until a Certificate of Compliance has been issued by the board of health.
Signed
Date
Application Approved By !,.�„'ta ...
Application Disapproved for the following reasons ry t, Hg41Y4
Permit No Issued
Date
ECK OR FILL IN WHERE APPLICABLE
THE COMMONWEALTH OF MASSACHUSETTS
FEE
BOARD OF HEALTH
OF
Application for Disposal Works fffunstrnrtiun 3rrmit
Application is hereby made for a Permit to Construct (:3-
or Repair ( ) an Individual Sewage Disposal
System at:
Location-Address
maw
or Lot No.
Address
Ingtaller Address
Type of Building Size Lot sq. feet
Dwelling—No. of Bedrooms .w 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 .>5 7 gallons.
Septic Tank-Liquid capacityik..P /gallons Length Width Diameter Depth
Disposal Trench—No) Width Total Length t Total leaching area sq. ft.
Seepage Pit No / Diameter t Depth below inlet._? Total leaching area s ft.
Other Distribution box ( ) Dosing tank ( ) .4) 4 era
et."
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 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 i n.f
Application Disapproved for the following reasons Date
Date
Permit No ' ,< Issued -
J
Date
by
THE COMMONWEALTH OF MASSACHUSETTS
BOARD OF HEALTH
OF
(IIertifirttte of ainnWlittnre
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 ./
�is#Insttl rr;nrkg (tinnsntrnrtinn Verntit
Permission ism hereby granted 6
to Construct ( ) or Repair ( ) an Individual?Sewage Disposal System
at No ...v.,
FEE
Street
as shown on the application for Disposal Works Construction Permit No - Dated
DATE
FORM 1255 HOBBS 8 WARREN, INC.. PUBLISHERS
Board of Health