435 Title 5 Application/Permits 1966 No....L... •
THE COMMONWEALTH OF MASSACHUSETTS
BOARD OF HEALTH
7 O F . fteent-6,¢,l al...
Apptiratinn fur 3iuprnoet i(r urks Crunstrttrtiun Wrath
Application is hereby made for a Permit to Construct (Vror Repair ( ) an Individual Sewage Disposal
System at:
Iorta:ler
or Lot No.
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 A.
Design Flow - 0 j..0..�7gallons per person per day. Total daily flow f Li 0 gallons.
•Septic Tank—Liquid capaci yr legations t Length
Width / t Diameter Depth
Disposal Trench—No. / Width Total Length._...'SJ Total leaching area sq. ft.
Seepage Pit No Diameter Depth below inlet tl leaching area sq. ft
/ .
Other Distribution box ( ) Dosing tank ( ) S H. GLry Oaf
Percolation Test Result 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'b the oacA:6fr 'Ith.
Signed -` ;22.
Date
' Date
Application Disapproved for the following reason•
Application Approved By
Permit No...�....1
Issued. .Pct^-•. " y /'/
Date
THE COMMONWEALTH OF MASSACHUSETTS
BOARD OF HEALTH
Cc � OF 4 C-y 4s>Y.friSq
IIertifirttte of QIInni.ptittnrr
THIS IS'4'O CE$T[8 ' That the Individual Sewage Disposal System constructed ( ) or Repaired (
<x 1 mace—
by / o 9Q 7/t-#_ -4 ,�.., J,; ft-- Installer
at
has been installed in accordance with the provisions of Articie?C1 of The State Sanitary( ode as descril)e in the
application for Disposal Works Construction Permit No 1 / e dated 'I / ��
THE ISSUANCE OF THIS CERTIFICATE SHALL NOT BE CONSTRUED AS A GUARANTEE THAT THE
SYSTEM WILL IFUN TION SATISFACTORY. 1 y
DATE >, 'Lit x ∎ ' �f r Inspector /'...: ( �. y`�'. d�i'✓j
U P
to
THE COMMONWEALTH OF MASSACHUSETTS
BOARD OF HEALTH
/Binpngz ri nrkg 11 nn5trnrtinn thrtnit
{, 7 �
Permission y5.hereby granted �gip'I
to Construct (t I ) or Re a4r ( )
at No
FEE
;icval Sewage Disposal System
street n !,
as shown on the application for Disposal Works Construction Perot No.L.I G Datedyaf 2
LT - . l
Board of Item
DATE
FORM 1255 HOBBS & WARREN. INC.. PUBLISHERS
No
THE COMMONWEALTH OF MASSACHUSETTS
Fes
BOARD OF HEALTH
re of Atie 'ti4PFI PTCA)
Application for Dispnsat i,i,nrks Urunstrnrtiun hermit
Application is hereby made for a Permit to Construct ( ) or Repair ( ) an Individual Sewage Disposal
System at:
/7/ ...3s 1 )2-
- ...5
rc 1,cL },
Lot N).
Owner Address
Installer
Address
Type of Building Size Lot Sq. feet
Dwelling—No. of Bedrooms z Fxpansion Attic ( ) Garbage Grinder ( )
Other—Type of Building No. of persons Showers ( ) — Cafeteria ( )
Other fixtures
Design Flow c Cl gallons per person per day. Total daily flow , el" gallons.
Septic Tank—Liquid capachy/rink-Akins' f.ength Width Diameter_____._ Depth
Disposal Trench—No. Gam— Width .2-i."? _._ Total Length.e_.Ct' Total leaching area Z-}0 sq. ft.
Seepage Pit No Diameter Depth below inlet n Total leaching area sq. ft.
Other Distribution box (
Percolation Test Results
Test Pit No. 1 ..
Test Pit No. 9
Dosi )
Performed by. V,. (.3 h/.. ` Date —Z.J' -6
minutes per inch Depth of Test Pit + (� Depth to ground water
minutes per inch Depth of 'fest Pit Depth to ground water
Description of Soil___,ke..e L..G�-xt-
Nature of Repairs or Alterations—Answer when applicable
Agreement:
The undersigned agrees to install the aforedescribed Individual Sewage Disposal System
the provisions of Article XI of the State Sanitary Code—The undersigned further agrees not to
operation until a Certificate of Compliance has been issued by the board of jiealth.
—S,c,s e- 'IL A /eaSore'_ .
Application Approved By
Signed
Application Disapproved for the following reasons-
in accordance with
place the system in
6,-2 3 --44,
n" J '
Permit No
Date
Date
Issued
Date