183 Application & Permit 1971•
THE COMMONWEALTH OF MASSACHUSETTS
BOARD OF HEALTH
et- OF `ilEry\261.:7' idv1
Application for Monad H1nrlts tnnstruc#ion Permit
Application is hereby made for a Permit to Construct ( ) or Repair (I )) an Individual Sewage Disposal
FEES. 0
stem at:
3
Itchltsfold
szte
11
rpe of Building
Dwelling—No. of Bedrooms
Other—Type of Building
Other fixtures
sign Flow
tptic Tank—Liquid capacity
isposal Trench--No
Lepage Pit No
ther Distribution box (
ercolation Test Results
Test Pit No. I
Test Pit No. 2
or Lot No.
Address
Address
Size Lot Sq. feet
Expansion Attic ( ) Garbage Grinder ( )
No. of persons Showers ( ) — Cafeteria ( )
gallons per person per day. Total daily flow
gallons Length Width Diameter Depth
Width Total Length
Diameter Depth below inlet
'escription of Soil
Dosing tank (
Performed by
minutes per incur Depth of Test Pit
minutes per inch Depth of Test Pit
gallons.
Total leaching area sq. ft.
Total leaching area sq. ft.
Date
Depth to ground water
Depth to ground water
!azure of Repairs or Alterations—Answer when applicable
rgreement:
The undersigned agrees to install the aforedescribed Individual Sewage Disposal System in accordance with
ne provisions of Article XI of the State Sanitary Code— The undersigned further agrees not to place the system in
peration until a Certificate of Compliance has been issued by the board of health.
tigned `%'
kpplication Approved By :C{ .--c1L Li- 2! 7- d.a`irjf/ t `n i ...L �._/ 97
Dare
application Disapproved for the following reasons
Permit No._y.L5—
V
THE COMMONWEALTH OF MASSACHUSETTS
BOARD OF HEALTH
Qt rtifha6 Af Qtnn tltanct
THIS IS TO CERTIFY, That the Individual Sewage Disposal System constructed ( ) or Repaired
Installer
Is been installed in accordance with the provisions of Article XI of The State Sanitary Code as described in the
>phcation for Disposal Works Construction Permit No dated
THE ISSUANCE OF THIS CERTIFICATE SHALL NOT BE CONSTRUED AS A GUARANTEE THAT THE
YSTEM WILL FUNCTION SATISFACTORY.
ATE Inspector
THE COMMONWEALTH OF MASSACHUSETTS
BOARD OF HEALTH
OF _ Fm
I
0
Disposal.pork, fdn sh xcttnn Permit
Permission is hereby granted.„. - a-- <--t ✓'
Construct ( Yl`) or Repair (✓) Ott Individual Sewage Disposal System
No e......_..- 31'}j✓. ) se.eeo
shown on the application for Disposal Works Construction Permit No Dated
Ut
Y
B
wed Le u[ Health
F
ATE
Mx' 1255 HOBBS 6 WARREN. INC.. PUBLISHERS