108 Title 5 Application/Permits 1992 i
i
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L IN WHERE APPLICABLE
CHECK OR F
FEE
THE COMMONWEALTH OF MASSACHUSETTS
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BOARD, OF�HEALTH
/W/Ci//7 �
. 'W OF %7/1/, a ,/ /
Application for 3isposnl orks Cltonstrurtion Permit
App ication is hereby made for a Permit to Construct ( ) or Repair (x) an Individual Sewage Disposal
i-77/7/245 /1frneatt/Me, AX-0e77Apyr/efv:v
System at:
n _ `Of 2/i0t.f /as 41/47-72/64/l2/64/ a nae,sw-lxr/64/
Address
Type of Building
Ier
Address 4197,31
3S4ZVAS1 Size Lot feet s
Dwelling—No. of Bedrooms r , , �/ Expansion Attic (% J Garbage Grinder (%'�-"
Other—Type of Building "Le,Al'�/..11 s of persons hi Showers (t) — Cafeteria (/j'
Other fixtures ile- .._g.Q'j.T
Design Flow ,i/G? gallons per
pe .r y
. Total flow-j/0'f /3 gallo
ns195
Septic Tank�j—fj i ca acit y�� g allons Len gth. #---. Wtdth_�_. ._/ Diameter Depth,,~
Disposal To nAa L ^CO. / Width.._1e' Total Length i Total
leaching area Se70.sq. ft.
Seepage Pit No Diameter Depth below inlet.. La a Total leaching area sq. ft.
Other Distribution box ( /) Dosing [tank ( ) �� ,y / /
Percolation Test Results Performed by..f/(/LZ4./fl7 CL/..rG../��G!/Date 3/42 9a
Test Pit No. I Z' 0 minutes per inch Depth of Test Pit 340_.. Depth to ground water i4//0/9 L.
Test Pit No. 2 tr tes per inch Depth of Test Pit Depth to round water
o e7.75 in?? /J Si e, cu1 y
Description of Soil 5//S SO/‘- /fi -gam r'a%iSe' s./"7c,
l/z0 ,z
/X,/ -2 G.d ors-La � -Tg syc-sy c
Nature of Repairs or Alterations—Answer when applicable /e9.W.ce7 577e0" `/
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 further agrees not to place the system in
operation until a Certificate of Compliance has been issued by the board of health.
Sigfir d V j..1/ D,
Application Approved By ..-.N-.. `�`^' .' � 2--
Application Disapproved for the following reasons
Date
Permit No Issued.
Date
by
THE COMMONWEALTH OF MASSACHUSETTS
BOARD OF HEALTH
OF
'Qtrrtifirat of (dnmplitt r
THIS Isay CERT , That the ndividual Sewage Disposal System constructed
at
!e'er
has been installed in accordance with the provisions of TITLE
application for Disposal Works Construction Permit No 1.9
THE ISSUANCE OF THIS CERTIFICATE SHALL NOT
SYSTEM W IL�]pUNCTION SATISFACTORY.
DATE DATE .I�J..t.e.C.. it�.../.L. %'_
> 4nstler
or Repaired (V1
N.
5 of The Sanitary Code a �d 'gibed in the
dated 7 il ..__.
BE CONSTRUED AS A GUAR TEE THAT THE
Inspector
THE COMMONWEALTH OF MASSACHUSETTS
/ 1 /
BOARD OF HEALTH
i r J
fdinponttl i,rorkn Otnnntrnrtion prrmit
Permission is hereby granted {.�W.,.Lg.---C2i.+..=✓1.1-49-.-.
to Construct ( ) or Repair (Yn Individual Sewage Disposal System
at No /F'- ki4-44.d.sry Sft
Street
as shown on the application for Disposal Works Construction Permit Nit_/y i/'4.2T(-... Dated�...7�. 7'/,/%)—Board'of Health
FEE Ii.....
.% L ? i}...._L./l�_.�".
ti i
DATE t
FORM 1255 A. M. SOLI%1N, BOSTON