Lot 212 Title 5 Application/Permits 1972 CHECK OR FILL IN WHERE APPLICABLE
No...5-02 S
THE COMMONWEALTH OF MASSACHUSETTS
BOARD OF {HEALTH
(bL OF +.�.
Appliratiun fur 31iuvunat i nrkn Qintuttrnrtinn Permit
FEE../ s c Q
Application is hereby made for a Permit to Construct (' ) or Repair ( ) an Individual Sewage Disposal
System at:
/ -/ a,
qj
Installer
4
or Lot No.
Type of Building
Dwelling—No. of Bedrooms Expansion Attic
Other—Type of Building No. of persons
Other fixtures
Design Flow ''••�� gallons per person per day. Total daily flow gallons.
Septic Tank—Liquid capaci i.gallons Length Width Diameter Depth
Disposal Trench No. Width Total Length Total leaching area to 0 sq. ft.
Seepage Pit No Diameter Depth below inlet Total leaching area sq. ft.
Dosing tank ( )
Performed by Date
minutes per inch Depth of Test Pit Depth to ground water
minutes per inch Depth of Test Pit Depth to ground water
Address
Size Lot Sq. feet
Garbage Grinder ( )
Showers ( ) — Cafeteria ( )
Other Distribution box ( )
Percolation Test Results
Test Pit No. I
Test Pit No. 2
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 y� " / y p
Application Approved By ,zyl u:uwi1< ..2Ii..t . l:l�p4cn ��.ss:r�zx.:•.tt!�i_I..97a-
(/ iJ na�L
Application Disapproved for the following reasons
Permit No 3a
Date
Issued.. - ._92..197.-
Date
by
THE COMMONWEALTH OF MASSACHUSETTS
BOARD OF HEALTH
OF
(gradient of (gamplintter
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
THE COMMONWEALTH OF MASSACHUSETTS
BOARD OF HEALTH
b./ft OF ,,tri-R-IA4rer97
FEE/-57°a
Binpon arks Toast:ruction tirrinit
Permission.iv/hereby granted .. al—D—gte
to Construmb( ; ) Repair ) an Indivith1 Sewage Disposal System
at No isj-A-1 "r asitiraw tid,,me,wat-er t
as shown on the application for Disposal Works Construction Permit No --Cd-P Dated•.cki
--------- ------
DATE
FORM 1255 HOSES & WARREN, INC.. PUBLISHERS
Wwiickt-