Lot 191 Title 5 Application/Permits 1972 .. .... ....... . . .. ....... .. fl • m T. ..... .....
CHECK OR PILL IN WHERE APPLICABLE
No.,-6 6
THE COMMONWEALTH OF MASSACHUSETTS
BOARD OF HEALTH
OF
Application fur 3Biupu.ttttl kiiorb Qluttntrttrtiuu 3Prmtf
a
Application is hereby made for a Permit to Construct (Kor Repair ( ) an Individual Sewage Disposal
System at:
1t4ddr` red
owner,- are 7 Address
p„ta6.r
or Lot Not
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 capacity/J-57 gallons Length Width Diameter Depth
Disposal Trench—No. Width Total Length Total leaching area...den._sq. 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 been issued by the board of health.
Application Approved By
Application Disapproved for the foiou
Sipped
&..J;. ,.147
Permit No.51 -5 Issued..0
D
4-7 ii7
by
THE COMMONWEALTH OF MASSACHUSETTS
BOARD OF HEALTH
OF
ftnrtificatr of Qlomplittnrr
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
No 'J a.S-
THE COMMONWEALTH OF MASSACHUSETTS
,5 ,
BOARD OF HEALTTrH,
LyL OF Ei PfZitaf f
Thtspns�rWorks Tnnnnirnrtinn ljrrmit
Permission is reby granted... e. ..� c P-�,
to Constrn (l or Repair ) an Indivi Sewage isposal System
at No__. �'� p
1. .1 :Cdr'aifft:kr%....VA!A:...
sit
as shown on the application for Disposal Works Construction p,e,a o..3.� Dated _..
j02717
... 071311-41—e I
Feet...{dL7
DATE
FORM 1255 HOBBS & WARREN, INC.. PUBLISHERS