21 Application & Permit 1969 No.__ ..d:...r
THE COMMONWEALTH OF MASSACHUSETTS
FEE
BOARD OF HEALTH
.-1-11-1„.-t OF PC7`:NtailF +ti71
Appliratiun far Pt pusal cr;urkn «tonstrurtiun j rrntit
Application is hereby made for a Permit to Construct ( ) or Repair (✓) an Indic idual Sewage Disposal
System at:
.v...L /�...._S: r�n tc e el / Y r or Lot Na.
Lacaiom
).Lls.e-itie .a.
P� y' Address
+- r nsta r D cr/ft-
Installer Installer D VVU S feet
Type of Building Size Lot q�
Expansion Attic ( ) Garbage Grinder ( )
Otheri—Type of Bedroom P
Other—Type of Building No of persons Showers ( ) — Cafeteria ( )
Other fixtures gallons.
Design Flow gallons per person per day. Total daily flow ga
Septic Tank—Liquid capacity gallons Length Total Length Width Total Diameter area Depth
sq. ft
Disposal Trench—No Width
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 . •t,-).NWI,I El, 41," 11`s` ‘t/. �
. . _. ..
41.....1.:.S.e . t-(ec 1 L Ci nei -r S, of
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 ed by the board o&health.
Signed ".. C L,x ` t C
y� na
l. ,.n L 26•1 ..j.Ltu- 17a 1.f'k/r
Application Approved By /`- Dme
Application Disapproved for the following reasons'
Permit No..3 & S
Dare
issued_Ary ) 7, Ire y
Date
by
THE COMMONWEALTH OF MASSACHUSETTS
BOARD OF HEALTH
OF
altrtifiratr of (Qumpliauur
THIS IS TO CERTIFY, That the Individual Sewage Disposal System constructed ( ) or Repaired (+k<
G.g.c..k—sr 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_,..,c., - 1 1 ' - i
THE ISSUANCE OF THIS CERTIFICATE SHALL NOT BE CONSTRUED AS A GUARANTEE THAT THE
SYSTEM WILL FUNCTION SATISFACTORY.
DATE ' - '1 Inspector
THE COMMONWEALTH OF MASSACHUSETTS
BOARD OF HEALTH
OF . -,. . FEE
No
!Disposal r,r arks Qinnstrurtinn jrrmit
Permission is hereby granted
to Construct ( ) or Repair ( :') an Individual Sewage Disposal System
at No -. - street
as shown on the application for Disposal Works Construction Permit No Dated
Board of Health
DATE
FORM 1255 HOBBS G WARREN. INC.. PUBLISHaRS