284 Application & Permit 1991 t:
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THE COMMONWEALTH OF MASSACHUSETTS
BOARD OF HEALTH
(try OF Af6 te-7-8/9"nla 7-4300
Appliration fur Digptwal Harks Trinutrurtion Prrttlit
lion is hereby made for a Permit to Construct ( ) or Repair (XI an Individual Sewage Disposal
Location-Address
S.12.•V'S 04/
Veikt CA:17.2cgc.zzo-t/
Installer
of Building
Dwelling—No. of Bedrooms
)ther—Type of Building No. of persons
Other fixtures
'n Flow .3;.1 gallons per person per day. Total daily flow in 0 gallons.
c Tank—Liquid capacitynetagallons Length JO Width tt,-- Diameter Depthl'
isal Trench—No ...3 Width a ' Total Length /6 5-2,Total leaching area....7M sq. ft.
age Pit No Diameter Depth below inlet Total leaching area sq. ft.
r Distribution box (X) Dosing tank ( ..).
ttion Test Results Performed by C4 -4,./f.e?‹../.4d.P4- Date 2-2.0—91
Test Pit No. I /Z-- minutes per inch Depth of Test Pit //4:. Depth to ground water 94
Test Pit No. 2 minutes per inch Depth of Test Pit /08 ' Depth to ground water S . "
eevo- 5,24.,::, ? J1/4-r, Co.,ie,se- 544/2> .1 t
..e.-1-a$/te:AL/
Lot No.
Address
Adorers
Size Lot 75-060 Sq. feet
Expansion Attic ( ) Garbage Grinder (K)
Showers ( ) — Cafeteria ( )
riptioti of Soil
.462 tooter-42>
6.e2
Ire of Repairs or Alterations—Answer when applicable 72321.4- 5isrts-24.7 723 06-
5"-rg z-z-4Ce>
eement:
The undersigned agrees to install the aforedescribed Individual Sewage Disposal System in accordance with
?rovisions of TITLE 5 of the State Sanitary Code—The undersigned further agrees not to place the system in
v ihtil a Certificate of Compliance has been issued b the b. rd of health.
Signete6
dication Approved By err dor
ate
ilication Disapproved for the following reasons•
Permit No
Date
Issued_
Date
THIS I$ Tfl0 C12t
enti
THE COMMONWEALTH OF MASSACHUSETTS
BOARD /OF HEALTH
OF /1/.4
Trrtifirafr of f nmplia
hare Ind��iv�.dual Sew. •sposal System constructed ( ) or Repaired (�
Instiller
een installed in ./orda ce with the provisions of TITLE 5 of The State Sanitary Code gs d scribed in the
ration for Disposal Works Construction Permit No i dated S.. ij'.2/
THE ISSUANCE OF THIS CERTIFICATE SHALL NOT BE CONSTRUED AS A GUARANTEE THAT THE
I'M WILL FUN TION S ISFACTORY.
E .. .
4.5 i -/
Inspector
THE COMMONWEALTH OF MASSACHUSETTS
BOARD OF HEALTH
oF f1- !— r+ <u-7.. 4"'N.
3dizpndttl ilUnrhi Tnnnfrurfintilgrrmit
Permission is hereby granted lett r..r.,e,.q...,_ -r
Bnstruct ( ) or Repair ( )) an Iiittididual Sewage Disposal System
t: _• so-at
own on the application for Dis/oral Works Construction Permit No r.«j..Dated
FEE
1255 A M,SIILKIN BOSTON
ms:d`of x.ae,