89 Title 5 Application/Permits 1990 Nora-1-90
CHECK OR FILL IN WHERE APPLICABLE
.P15.
iSxC
Teti 6,0,dll11..L 3rioo-Addrcsa
.....staller .....---
vslaller
Type of Building Garbage Grinder (X)
Dwelling—No. of Bedrooms 3 Expansion Attic ( ) g
P
Other—Type of Building
No. of persons Showers ( ) — Cafeteria ( )
Other fixtures
THE COMMONWEALTH OF MASSACHUSETTS
BOARD OF HEALTH
c ,' OF...L/..(% ferAleC _...._.._....._._
Oration for Disposal Works 1tonstrnrtinn jrrmit
hereby made for a Permit to Construct ( ) or Repair Q) an Individual Sewage Disposal
Address
gallons per person per day. Total dail flow 4.9 gallons.
Destgn Flow T,Sr (O Width ti�r Diameter Depth
ft
Disposal Trench—No. aJ...._.... Width.....? Total Length....%S._..Total leaching
Seepage Pit No Diameter Depth below inlet Total leaching area.. sq. ft.
Other Distribution box o
Percolation Test Results Performed by ' �����
Test Pit No. l..Z- minutes per inch
Test Pit No. 2 minutes per inch
Septic Tank-Liquid capacity/gallons Length t t ... iame
leachin area.3 0 -sq
�.7
(x) Dosing tank )
Description of Soil
pr
Date.G 'Z.S ' 90
e t... . . �•
Depth of Tes[ Pit....�fw Dep[h to ground water..V Q
Depth of Test Pit Depth to ground water
CO22der efer`re`t r° Bt—
Nature of Repairs or Alterations—Answer when applicable.._... e. M— r fir
�2Ef..?ke9«i?• ELY/S?...��i •se�,r°_r..0 2v
Agreement:
The undersigned agrees to install the aforedescribed Individual Sewage Disposal System in accordance with
the provisions of TITLE 5 of the State Sanitary Code—The undersigned ther agrees not to place the system in
410 operation until a Certificate of Compliance ha issued bbyy the •• dOtth. O, c amt
Signed...1e.IiY�1l�� �[/—Y f ---
// lel ` / v
i
Application Approved By ®-'
Application Disapproved for the following reasons•
Date
Permit No
Issued
by
at
has been installed in accord ks with the provisions Nof o,ITLE S' State Sanitary dat Code a=described ip0e
application for Disposal Woks Construction Permit No 5T
THE ISSUANCE OF THIS CERTIFICATE SHALL NOT BE CONSTRUED S A GUARANTEE THAT THE
SYSTEM WILL FUNCTION SATISFACTORY.
DATE y — — E a Inspector
THE COMMONWEALTH OF MASSACHUSETTS
BOARD OF HEALT
OF
ertifiratt`.d Complimit
he Individual Sewage Disposal System constructed ( ) or Repaired (K)
THIS I 0 CERTIFY
all
THE COMMONWEALTH OF MASSACHUSETTS
2/ — �l0 {� BOARD�E 4EflL b r
OF
No
Permission is hes9b
to Construct ( ) aCIDR
at No
as shown on the gppl tion
33in}1nsa1
r,Ic.;
hgrtgg t4antit
FEE
Sedva�c
atlt I�3idi�val —f
Disposal Systan
street,
for Disposal Works Construction Perrni
/6 /9 i0
DATE
FORM 1255 A. M. SULKIN,
BOSTON
Board of Healtb