Lot 46 Title 5 Application/Permits 1968 CHECK OR FILL IN WHERE APPLICABLE
No.3 d.�._
THE COMMONWEALTH OF MASSACHUSETTS
, BOARD OF HEALTH
OF
Fn
Appiirutian far Dinpasttl Works iLlanstrurtian l3rrmit
Application is hereby made for a Permit to Construct (V or Repair ( ) an Individual Sewage Disposal
System at:
Lmatir. dress !�
ki+/ } tfriaa
- t.
Installer
Type of Building
Dwelling—No. of Bedrooms
Other—Type of Building
Other fixtures
Design Flow 0.. gallons
Septic Tank—Liquid capacit gallons
Disposal Disposal Trench—No. N idth
Seepage Pit No Diameter
Other Distribution box ( ) Dosing tank ( ) 'p
Percolation Test Results Performed by i f" 29('e+ve•*j Date la I..b..Lf..7
Test Pit No. 1 1/ tninutes per inch Depth of Test Pit .34. 00 Depth to ground water
Expansion Attic (
No. of persons
Address
Size Lot Sq. feet
Garbage Grinder ( )
Showers ( ) — Cafeteria ( )
per person per day. Total dai
Length Width
Total Length
Depth below inlet
ly flow 41 0 P gallons.
Diameter Depth _-
Total leaching area 974.0...sq. ft.
Total leaching area sq. ft.
Test Pit No. 2 minutes per inch Depth of Test Pit i Depth to ground water. .£rz
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 issty d by the board o$J}gdth.
Application Approved By
Signed
G2%
a-enkt IL.
Jr] 2-
Date
Application Disapproved for the following reasons
CHECK OR FILL IN WHERE APPLICABLE
No..
THE COMMONWEALTH OF MASSACHUSETTS
BOARD OF HEALTH
Application for fisponal rl,arks Qtnnstrn#inn Permit
-7n
Application is hereby made for a Permit to Construct ( LYCRepair ( ) an Individual Sewage Disposal Lge
System at:
.14/2B-JAIJA2a s t p 6 DI2.1 V...6— tie 9`S �a
-Location.Address
`ediefu.c ad. i rnc.r Address
FEE
Installer
Type of Building
Dwelling—No. of Bedrooms
Other—Type of Building
Other fixtures
Design Flow
Septic Tank—Liquid capacity
Disposal Trench—No.
Seepage Pit No Diame
Other Distribution box ( )
Percolation Test Results Perfo
Test Pit No. 1 faint
Test Pit No. 2...1.I minute
Address
Size Lot.....J... -± Sq. feet
Expansion Attic ( ) Garbage Grinder ( )
of persons Showers ( ) — Cafeteria ( )
No
gallons per person per day. Total daily flow gallons.
gallons Length...___.... \Vidth Diameter Depth
Width Total Length Total leaching area sq. ft.
ter Depth below inlet Total leaching area sq. ft.
Dosing tank ( )
rmed by Date �
es per inch Depth of Test Pit.._..r Depth to ground water.) i
s per inch Depth of Test Pit.. ?t." Depth to ground water
Description of Soil_.
I-
.... . u.- .- -n n �
.,UdJe: Lei rr,.�t ons Answer wha ap aablev -e.a r ea.d Pi ,.f:C.¢.a. ..-- --
Nature of Repairs r Alt tions—Answer wh appliabl __....____(,�(.-�--•
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
Application Disapproved for the following reasons•
Date
Date
Date
Permit No Issued
Date
THE COMMONWEALTH OF MASSACHUSETTS
BOARD OF HEALTH
flCdrtifiratr of alnmpliatur
THIS IS TO CERTIFY, That the Individual Sewage Disposal System constructed (. ) or Repaired
by :�..,r.4..LI 4&..U._
at .t.tmostc <r / ' 4.
has been installed in acMrdance with the provisions of Article XI of The State Sanitary Code as described in the
application for Disposal Works Construction Permit No '! dated_..._.._..._.:..:._i At
THE ISSUANCE OF THIS CERTIFICATE SHALL NOT BE CONSTRUED AS A GUARANTiE THAT THE
SYSTEM WILL FUNCTION SATISFACTORY. -
DATE )....t.et :si.a ' li-a.d' Inspector....:.-4c-6 : •:y....ail .Ji4 t941..c.y.
No
THE COMMONWEALTH OF MASSACHUSETTS
' '' _ BOARD!�F • {1�5ALThH
OF
Oispuuat
cr;
nrhs'Stfrurtian Frrmit
Permission is hereby granted
to Construct ( ) of Repair ( ) an fndivid of Sewage Disposal System
at No
pSBxt>
as shown on the application for Disposal Works Construction"Permit
DATE
FORM 1255 HOBBS & WARREN. INC.. PUBLISHERS
FEE
Dated
Board of Health