764 Title 5 Applications/Permits 1964 THE COMMONWEALTH OF MASSACHUSETTS
FEE..
BOARD OF HEALT
Appliratiun tar lispnsat lurks !Iunstrurtinn /Intuit
Application is hereby made for a Permit to Construct ( ) or Repair (
Zstem at:
I y
I valfor re„
t mnaue
d
Type of Building
Dwelling--No. of Bedrooms � '! '- ' �j Expansion Attic (
Other—Type of Building No/ of persons
Other fixtures
)esign Flow gallons per person per day. Total daily flow gallons.
1eptic Tank—Liquid capacity gallons Length Width
)isposal Trench— No. Width Total Length
Seepage Pit No Diameter Depth below inlet
)ther Distribution box ( ) Dosing tank ( )
tercolation 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
an Individual Sewage Disposal
1
/ 96
2
Address
Size Lot Sq. feet
Garbage Grinder ( )
Showers ( ) — Cafeteria ( )
Diameter Depth
Total leaching area sq. ft.
Total leaching area sq. ft.
Description of Soil
Vature of Repairs or Alterations—Answer when applicable._f" W— r4 t-V „Ai it
t
Agreement:
The undersigned agrees to install the aforedescribed Individual Sewage Disposal System
he provisions of Article NI of the State Sanitary Code— The undersigned further agrees not to
>peration until a Certificate of Compliance has been issued by the boa Ith.
//nn
Signed 1 '. '-..ml it?
Application Approved By rj. fr "- /r vie6.4s1
in accordance with
place the system in
7 -/3—� `!
Date
Date
Application Disapproved for the following reasons'
Permit No
THE COMMONWEALTH OF MASSACHUSETTS
BOARD OF HEALTH
OF_..Cl F,. (F.?ip1't::.
tlTrrtifirnir of (nntplinnrr
THIS IS TO CERTiF1TrThat the jndividunl Sewage Disposal System constructed ( ) or Repaired (V)
w
as been installed in accordance with the provisions of Article X1 of The State Sanitary Code as,described in the
pplication for Disposal Works Construction Permit No .. dated _f.3.`!y} / !'
THE ISSUANCE OF THIS CERTIFICATE SHALL NOT BE CONSTRUED AS A GUARANTEE THAT THE
;YSTEM WILL FUNCTION SATISFACTORY.
)ATE - Inspector - - Imo' ' - " � •�.
slo
THE COMMONWEALTH OF MASSACHUSETTS
BOARD OF HEALTH
.i1/4-4-774/
OF
Dinpnnol 3Bprhn,lnotifrurfinn Vrrmif
Permission is hereby granted -� I d4 a Lit"
FEE
o Constructj ),pr RTair S ) ay I divide Sewage Disposal System
Street -
.s shown on the application for Disposal Works Construction Permit No i " Dated T'L`h» � /
.4-4- '- t JI A r" a i
)ATE L9' ." f 2 1 i- - Board of Health Y
ORN 1255 HOBBS & WARREN. INC.. PUBLISHERS