504 Title 5 Applications/Permits 1964, 1966 No 7{! FEE
THE COMMONWEALTH OF MASSACHUSETTS
BOARD OF HEALTH
Cja 1 OF... .' tv',.`aloes
Applirntiun fur Uinpunttl Works Qlunntrnrtiun 1 rrmit
Application is hereby made for a Permit to Construct ( or Repair ( ) an Individual Sewage Disposal
System at:
3-05'it. f*4
Type of Building 6 Vq' ' 1
Dwelling—No. of Bedrooms Expansion Attic
Other—Type of Building No. of persons
Other fixtures
Design Flow ,77 gallons per person per day. Total daily flow gallons.
Septic Tank—Liquid capacitys�OP._gallons ength Width Diameter fT��tepth
Disposal Trench— No 3 Width Total Length SO Total leaching areaa.... G sq. ft.
Seepage Pit No Diameter Depth below inlet Total leaching area sq. ft.
Other Distribution box Dosing tank ( )
Percolation Test Result Performed by Date
Test Pit No. I 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
or rot
4Ad -
Address
Size Lot Sq. feet
Garbage Grinder ( )
Showers ( ) — Cafeteria ( )
Description of Soil
Nature of Repairs or Alterations—Answer when applicable
Agreement:
The undersigned agrees to install the aforedescribed Individual Sewage Disposal System inraccordance with
the provisions of Article XI of the State Sanitary Code—The undersigned further agrees not to phce the system in
operation until a Certificate of Compliance has been listed hh the board o health
Signed /td;-C
Owe
Application Approved By 0401 4 t l -Initert f d1 I96 y_
D:I<
Application Disapproved for the following reasons'
J �]], Date
No._-( d Issued...l4!c>t.P2nateT 6 1.1-6.�
at
has been installed in accordance with the provisions of Artic y
leXI of The State Sanitary ���,,,pppde as described in the
application for Disposal Works Construction Permit No { dated e76r(pb r
THE ISSUANCE OF THIS CERTIFICATE SHALL NOT BE CONSTRUED AS A GUA ANTEE THAT THE
THIS ISy c
50$ )
jdo•-a !7
THE COMMONWEALTH OF MASSACHUSETTS
BOARD OF HEALTH
d y
rrtifirate of Coittpliatur
TGIFY That the Individual Sewage Disposal System constructed (Vc or Repaired
Installer
SYSTEM L¢@ UNCTION SATISFACTORY.
DATE """" /3, /94r
No 7d
Inspector
THE COMMONWEALTH OF MASSACHUSETTS
BOARD OF HEALTH
OF i
Rayon einnr�s totruffinn f rrmU
1 Sewage Disposal System
Permission is rehy granted
to Construct ( ), nLR pir d-fin Indivi
at No —CC
do,
FEE
as shown on the application for Disposal Works Construetio
DATF 2 ;(t igt
FORM 1255 HOBBS & WARREN. INC., PUBLISHERS
Street J
IeernAit t�*o.-�/ Dated
AA nee
No....%..lF
FEE
THE COMMONWEALTH OF MASSACHUSETTS
BOARD .QF HEALTH
OF.....lj ' ?
Application fur Jispasttl
r
Application is hereby made for a Permit to Construct
System at:
SO I/ 11C-ti <, .
cui
urks Cltuustrurtion rrmii
or Repair (✓) an Individual Sewage Disposal
or Lot No.
s-..
Addreaa/
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
Design Flow 7 gallons per person per day. Total daily flow gallons.
Septic Tank—Liquid cap city(.&+C 41gallons Length Width Diameter Depth
Disposal Trench—No. Width Total Length Total leaching area sq. it
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(Ttig, _
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 b tJry the rd/of health.
,$igned �)f'
XJwt•� N. - p.144-r.. rate
e
Date
Application Approved By
Application Disapproved for the following reasons
Permit No
Ik5
Da e
Issued.._L4./ 1! !!6:
THE COMMONWEALTH OF MASSACHUSETTS
BOARD OF HEALTH
OF
rrlifiratr of (IIn 1 pliancy
THIS (SJTO.CERTIFY, That the Individual Sewage Disposal System constructed ( ) or Repaired (/')
by i1 &4 �i,kii- c-
at 5 c y eri—r//I - rya . ;I- t SIR
has been installed in accordance with the provisions of Article XI of The State Sanitary Code a§§ described ip�the
application for Disposal Works Construction Permit No 1 to i dated'
THE ISSUANCE OF THIS CERTIFICATE SHALL NOT BE CONSTRUED AS A GUARANTEE THAT THE
SYSTEM WILL FUNCTION SATISFACTORY.
DATE. n"---A ( 13 t J 1 i Inspector C.(4401 '4k
THE COMMONWEALTH OF MASSACHUSETTS
BOARD OF HEALTH
11 OF ^S L
Uilpluitt (,rkny �� nnzlrurtinll Vantii
Permission is hereby granted.. �t)LK^ hjstA- f
to Construct ( ) or Repair, ( ) n Individual Sewage Disposal System
at No j.0 I-----.L_yl .a.. s e« /
as shown on the application for Disposal Works Constructions emit No / 1: / ,,Dated I9 !7i
re_litLaAf 4:1-44
Board of I Ith
FEE
DATE ))LM-t(
FORM 1255 HOBBS S WARREN. INC.. PUBLISHERS