28 Title 5 Application/Permits, 1979 CHECK OR FILL IN WHERE APPLICABLE
No....t�£..7 ca—
THE COMMONWEALTH OF MASSACHUSETTS
BOARD OF HEALTH
F Appliratiutt fur fiopuoal Wurks u crud n Permit
Application is hereby made for a Permit to Construct ( ) or Repair (i<n Indisidual Sewage Disposal
System at:
AR- tiont4
FEE.....—�.... 00
Installer
Type of Building
Dwelling—No. of Bedrooms
Other—Type of Building No
Other fixtures
Design Flow gallons per person per day. Total d
Septic Tank--Liquid capacity gallons Length Width
Disposal Trench—No. Width Total Length
Seepage Pit No Diameter Depth below inlet
Other Distribution box ( ) Dosing tank ( )
Percolation Test Results Performed b
Test Pit No. 1 minutes per inch
Test Pit No. 2 minutes per inch
or Lot No.
Address
Address
Size Lot Sq. feet
Expansion Attic ( ) Garbage Grinder ( )
of persons Showers ( ) — Cafeteria ( )
flow gallons.
Diameter Depth
Total leaching area sq. ft.
Total leaching area sq. ft
Date
Depth of Test Pit Depth to ground water
Depth of Test Pit Depth to ground water
Description of Soil
Nature of Repairs or Alterations—Answer when applicable—(, la !o 0'WI,6 a
Agreement:
The undersigned agrees to install the aforedescribed Individual Sewage Disposal System in accordance with
the provisions of?IT 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.
Signed._�/. �
/.
Application Approved By -
9fc� i sat. II.Z.j
Date
Application Disapproved for the following reasons'
Date
Permit Permit No 2.7...t — Issued._> ..1/4-5.T...�. .�
Date
by
THE COMMONWEALTH OF MASSACHUSETTS
BOARD OF HEALTH
OF
Qiertifirtttr of Qinmplittnrr
THIS IS TO CERTIFY, That the Individual Sewage Disposal System constructed ( ) or Repaired ( )
Installer
at
has been installed in accordance with the provisions of TITLE 5 of The State Sanitary Code as described in the
application for Disposal Works Construction Permit No dated
ISSUANCE OF THIS CERTIFICATE SHALL NOT BE CONSTRUED AS A GUARANTEE THAT THE
SYSTEM WILL FUNCTION SATISFACTORY.
DATF Inspector ----
Permission
to Construct (
at No
as shown on the
DATE
THE COMMONWEALTH OF MASSACHUSETTS
BOARD OF HEALTH
OF
Ois.pnsttl 3urku Qlnnstrurtinn Permit
is hereby granted
) or Repair ( ') an Individual Sewage Disposal System
FEE
Street
application for Disposal Works Construction Permit No Dated
FORM 1255 HOBBS 8 WARREN
INC.. PUBLISHERS
Board of Health