39 Application & Permit 1983 THE COMMONWEALTH OF MASSACHUSETTS
BOARD OF HEALTH
OF
Application for flis}lasal Rucks (n usfractian hermit
Application is hereby made for a Permit to Construct ( ) or Repair ( ✓4 an Individual Sewage Disposal
System at:
3y 01
Location-Address / ,- •.• 3f'Q o Int ,.i/i
�f , Address ___
._ ...L.. ns Address
Installer
Type of Building Size Lot Sq. feet
Dwelling—No. of Bedrooms ) Garbage Grinder ( )
Other—Type of Building Showers ( ) — Cafeteria ( )
Other fixtures
Design Flow
Septic Tank—Liquid capacity
Disposal Trench— No.
Seepage Pit No
Other Distribution box
Percolation Test Results 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
No.
Expansion Attic
of persons
allons per person per day. Total daily flow gallons.
gallons Length
Width Total Length
Diameter Depth below inlet
Dosing tank ( )
\ridth Diameter Depth
Total leaching area sq. ft.
Total leaching area sq. it.
Description of Soil
Nature of Repairs o _Alterations-A wer when applicable ie et �e l "
Agreement:
The undersigned agrees to install
the provisions of TITLE 5 of the State
operation until a Certificate of Compliant
the aforedescribed Individual Sewage Disposal System in accordance with
Sanitary Code— The undersigned further agrees not to place the system in
e has been issued by the board of health.
Application Approved By
Application Disapproved for the following now
Permit No
la . 7)
Issued
Date
Date
La
`7?
y,
THE COMMONWEALTH OF MASSACHUSETTS ry BOARD OF HEALTH
0`A: OF.. `L.i' l.-' r„r,�...�;) .rte
Otrrtifiratr of Qtompliaurr
THIS IS TO CER
lidifiiditCal Sewage Disposal System constructed ( ) or Repaired (�} -
K
1)y ler
v
3 / '
at
I h stalled in accordance with the provisions of TIT L3 5 uThe State Sanitary Code as d ribed in the
dated �/ar/-_a-j
THE ISSUANCE OF THIS CERTIFICATE SHALL NOT BE CONSTRUED ASA GUAR TEE THE
SYSTEM WILL U7TIIO�! SATISFACTORY.
DATE !O}/ rl S Inspector _ ...._..../
has been installed
application for Disposal Works Construction Permit No
THE COMMONWEALTH OF K�
APt/SSACHWSET
�
BOARD OF HEALTrS
OF
fliopooaf l toiii t tr rtton jrrmit
Permission is hereby granted % a.
to Construct ( ) or repair (V) a1j-.4ndivirlual Sewage Dieya5a1 'System ; �/ P
at No / (' LJC" (< C. ' 1�5 •l'
r p
-Strcet e J 1
as shown on the application for Disposal Works Construction Perm$ Noy 1 i✓.-� �'iate4
7/31/c3
FEE i'rz
DATE
FORM 1255 A
ULKIN, INC.. BOSTON
t
h