Lot 194 Title 5 Application/Permits 1972 CHECK OR FILL IN WHERE APPLICABLE
F„.1-5700
THE COMMONWEALTH OF MASSACHUSETTS
/� $OARD '�/OF HEALTH
et- OF /l T!11-a1'YI
Appliratinn fur DDispnsttl i,nrlus Tonstrnrtinn 1 rrmif
Application is hereby made for a Permit to Construct (✓ ) or Repair ( ) an Individual Sewage Disposal
System at:
cti ctatfli.. cfsa t ,
2d9t ts p— Address
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 capacityP A.gallons Length Width Diameter Depth
Disposal Trench—No Width Total Length Total leaching area.l O.Q..d...so. ft.
Seepage Pit No Diameter Depth below inlet Total leaching area sq. ft.
Other Distribution box ( ) Dosing tank ( )
Percolation Test Results Performed by Date
Test Pit No. 1 minutes per inch Depth of Test Pit Depth to ground water
Test Pit No. 2 minutes per inch Depth of Test Pit Depth to ground water
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 be issued by the and of health.
Signed - �°6
Application Approved By .Li`....%k
Application Disapproved for the following reasons
Permit No - s) J
Date
Issued L�-"- .-- c1 )
Dat
THE COMMONWEALTH OF MASSACHUSETTS
BOARD OF HEALTH
Lk OF .f aewrF
(II rtifiratr of flu liana
THIS IS T CERTIFX,.ieatIlie,Individual Sewage Disposal System constructed (gor Repaired
by (1 ... .. .. ..1. ..... taluier
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 „psi„ dated-----Of.AA_.ALP_.J.ila...
THE ISSUANCE OF THIS CERTIFICATE SHALL NOT BE CONSTRUED AS A GUARMNTEE THAT THE
SYSTEM WILL FUNCTION SATISFACTORY. ,/
DATE Inspector
LS-5[:Q_....te+(._ ....�_�.Z..Z.. ..—ic-L ^Rd.L...iL
THE COMMONWEALTH OF MASSACHUSETTS
BOARD OF HEALTH
0.
Elinpooxf,, arks Qtnnnfrttrtinn tirrmif
m
Permission iyhereby granted-............:_cv.:e.a_..l_::......:!..0..aa..h
to Construe (✓) or Repair ( ) an Individual Sewage Disposal System
at No c..'--_f [ .T [; a:_ .:.. .r i,.d✓...l�ir5.
Street
as shown on the application for Disposal Works Construction Permit No.k...a Dated...:..i.:<,;_.c ..k'..j.%1..L.
DATE
FORM 1255 HOBBS & WARREN, INC.. PUBLISHERS
Board of Health