Lot 199 Title 5 Application/Permits 1972 CHECK OR FILL IN WHERE APPLICABLE
THE COMMONWEALTH OF MASSACHUSETTS
,(� BOARD OF�y HEALTH
CAL OFt'c2-.M
Apptiratinn far 1ispaual Marks Cnnnstrnrtinn ljtrtnit
Fax. ..LP_
Application is hereby made for a Permit to Construct ( or Repair ( ) an Individual Sewage Disposal
System at:
21- 1f f
or Lot No.
Owner Address
42.._.. . ..x,
(71.�
�aller Address
Type of Building Size Lot Sq. feet
Dwelling—No. of Bedrooms Expansion Attic ( ) Garbage Grinder ( )
Other—Type of Building No. of persons Showers ( ) — Cafeteria ( )
Other fixtures
Design Flow gallons per person per day. Total daily flow gallons.
Septic Tank—Liquid capacityL iligallons Length Width Diameter De th
Disposal Trench—No. Width Total Length Total leaching arca—.-a G 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
Other Distribution box
Percolation Test Results
Test Pit No. 1
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
Application Approved By .. .. .. ._ .... °n - _17{1.9..7 -
Application Disapproved for the following reasons
Permit No
Issued., !i{ : o-7.1..11.1 as
DaK
by
THE COMMONWEALTH OF MASSACHUSETTS
BOARD OF HEALTH
OF
Trrtifirtttr of flinmptittnrr
THIS IS TO CERTIFY, That the Individual Sewage Disposal System constructed ( ) or Repaired ( )
SwF:E r
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
No,.. .a17
THE COMMONWEALTH OF MASSACHUSETTS
BOARD OF HEALTH
attic of arCttn Ealr
FEE. 37 ca
ilkspoott crorks��Oiopstrurtinn Permit
Permission is hereby granted.... ... ._9... ..tC:�....lGd
to Construcct( � of,Repair ) an Individ Sewage psis osal System
at No T J-1 )3L !crvtft t i4-L.tal
Street
PP Disposal '-4
as shown on the application for Dis osal Works Construction mit No2 Date
Boyd n[ H
DATE
FORM 1255 HOBBS & WARREN, INC., PUBLISHERS