394 Application & Permit 1979 No....R 63
FEE 67 0
THE COMMONWEALTH OF MASSACHUSETTS
BOARD OFHHEALq.--TH
LJJ
*.ppliratiun fur fthut mar lflurkz Cnunstrurtiun hermit
Application is hereby made for a Permit to Construct ( ) or Repair (Kan Individual Sewage Disposal
System at'
._••• ..••• '�' Lo n- ldd�msJ / or Lot No.
fj?It/%� O.y ^l4.1' 1
e. j3 Address
Installer
Type of Building
Dwelling—No. of Bedrooms
Other—Type of Building
Other fixtures
Design Flow gallons p
Septic Tank—Liquid capacity gallons
Disposal Trench--No. Width
Seepage Pit No Diameter Depth below inlet
Other Distribution box ( ) Dosing tank ( )
Percolation Test Results Performed by
Test Pit No. 1 minutes per inch
Test Pit No. 2 minutes per inch
Address
Size Lot Sq. feet
Expansion Attic ( ) Garbage Grinder ( )
No of persons Showers ( ) -- Cafeteria ( )
er person per day. Total daily flow gallons.
Length Width Diameter Depth_.__ .-
Total Length Total leaching area sq. ft.
Total leaching area sq. ft.
Description of Soil
Date
Depth of Test Pit Depth to ground water
Depth of Test Pit Depth to ground water
Nature of Repairs or Alterations—Answer when applicable_.
li
Agreement:
The undersigned agrees to install the aforedescribed Individual Sewage Disposal System in accordance with
the provisions of TITLE^. 5 of the State Sanitary Code—The undersigned further agrees not to place the system in
operation until a Certificate of Compliance has bee issued by the board of health.
Signed✓�� 97:1- �:'" s'Y �. '
Application Approved By
Application Disapproved for the following reasons
Set _Lyn
Oat
/ G
Perm NoC
3 issued__6�aze psi-i-9 Tar
by
THE COMMONWEALTH OF MASSACHUSETTS
BOARD OF HEALTH
OF
Trrtifirttte of QiLnm}Tlittnre
THIS IS TO CERTIFY, That the Individual Sewage Disposal System constructed ( ) or Repaired ( )
Instiller
at
has been installed in accordance with the provisions of TITLE 5 of The State Sanitary Code as described in the
application for Disposal Works Construction Permit No
dated
THE ISSUANCE OF THIS CERTIFICATE SHALL NOT BE CONSTRUED AS A GUARANTEE THAT THE
SYSTEM WILL FUNCTION SATISFACTORY.
DATF Inspector
THE COMMONWEALTH OF MASSACHUSETTS
BOARD OF HEALTH
/ OF
No
llopnottl 'Marko Otnnotrurtinn remit
Permission is hereby granted e ' ' - " -
or Repair Construct ( ) e p i // Sewage Disposal System
at No seen
afr ( ) an n
as shown on the application p osal lication for Disposal Yorks Construction Permit No Dateq <
FEE'
DATE
FORM 1255 HOBBS & WARREN. INC.. PUBLISHERS
Board of Health