Lot 193 Title 5 Application/Permits 1972 -
l
ERE APPLICABLE
CK OR PILL IN\
No.T6U
Frg.L.5. 0 A
THE COMMONWEALTH OF MASSACHUSETTS
BOARD OF HEALTH
-1-111, OF
Application fur Disposal
arks Ql nstrurtinn Zirrmit
Application is hereby made for a Permit to Construct (✓) or Repair ( ) an Indic idual Sewage Disposal
System at:
1 9 2
t. ca
07 d`/� a Address
or Lot No.
V instill¢ 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 1 �1 gallons per person per day. Total daily flow gallons.
Septic Tank—Liquid capacityk1 gallons Length Width Diameter Depth
Disposal TrenchNo Width Total Length Total leaching area 1OQJ/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 NI of the State Sanitary Code—The undersigned further agrees not to place the system in
operation until a Certificate of Compliance has been - s d by the ar of health.
nn t
Signed .:
Application Approved By _lf:.
Application Disapproved for the following reasons•
Permit No__5 2/
Issued F i 97 a—
o
by q {
at 1 q ,t.fl.ysk�ic�l+n• i464.44t- k
THE COMMONWEALTH OF MASSACHUSETTS
BOARD OF HEALTH
OF_ !!`�7
.�rrtifirttfr of & nunncr
THIS IS O CERTIFY, ' $t jhe Individual Sewage Disposal System constructed Qom ) or Repaired
aelj R.4
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 WJLL FUNCTION SATISFACTORY.
DATE 04,-8:U P.p,...1_...%/sn- Inspector 1.44714-17 .21
No
THE COMMONWEALTH OF MASSACHUSETTS
�t
BOARD OF HEALTH
tj, OF
3lis}tosttl into (IIonnirurtion tirrittit
II
Permission is,hereby granted - - • c'l.=rv}
to Construcft. (f;) o; R pair ( ) an Individ Sewage i.sposal System
at No ,.
street
as shown on the application for Disposal Works Construction Permit No.... Dated
DATE
FORM 1255 HOBBS & WARREN. INC.. PUBLISHERS
FEE
Board of Neallh