396 Application & Permit 1995 FE±'
THE COMMONWEALTH OF MASSACHUSETTS
BOARD OF HEALTH/,J
€5, OF /i/O/LT7t/lrv7W/
Oration for flispozal Marks Cnonstrurtion jrrmit
;f /king is hereby made for a Permit to Construct ( ) or Repair ( ) an Individual Sewage Disposal
S2'4225' a/,�///L.D / Y ,C37&51 Li44.5""/z Vi0
go?,---Z-Avt%' 191 Syd- Sr e f line �,imAzo,u /t:%
Owner Address
Installer Address
Type of Building ��}} pp
Size Let1'S 72 Sq. feet
Dwelling—No. of Bedrooms�7p ��� Expansion Attic ( ) Garbage Grinder Rio
Other—Type
yper fixtures Building --1 No. of persons Showers (I) — Cafeteria ( )
/ . cc...e,P%.'rl/2G. eg/nT / r1J
Design Flow /��y gallons per person per daay. Total daily flow—�/..0 3 gallons. _5
Septic Ta,-,r ,»id capacit)t gallons en�th. D.L.a. Width Diameter Depth..
Disposal TrtIZ -No. / Width ../a" otal Length_�/n B Total leaching area sq. ft.
(a
Seepage Pit No _ Diameter Depth below inlet !" Total leaching area sq. ft.
Other Distribution box (7) Dosing jan)c C ��� U� Date ��y�9'�
Percolation Test Results Performed by.. liC/J.S n p ��T�7
Test Pit No. I Z'O minutes per inch Depth of Test Pit t/ Depth to ground water
Test Pit No. 2 mitytvtes per inch Depth of Test Pit Depth to ground water
Description of Soil../iliia —..aa C! ,flit..",Y �C%�./%L `r/ z Onm ..saeo
/a.y _.3 zoa a.-ce/ a -.a r� 'sdc )-9/
57/74(14) tOk/L.. 9 iettearag .C.42.7 ' C., £7S. r •.z
Nature of Repairs or Alterations—Answer when applicable !CO-ePya4.°`
27"e"—e . -Pr'
Agreement: CL 14
The undersigned agrees to install the aforedescribed Individual Sewage Disposal System in accordance with
the provisions of TITLE 5 of the State Environmental Code—The undersigned further agrees not to place the
system in operation until a Certificate of Compliance has been issued by the board of health.
Si ed X e(2 -
Application Approved By
Application Disapproved for the following reasons:
Permit No. Issued
THE COMMONWEALTH OF MASSACHUSETTS
BOARD F HE / .OF if- THj�,�,� ((�a�1�
"'/ Certificate of CompHa
/figs IS %To CC/R,TI,7 ihut the vjeaal SeT Disposal System constructed ( U ) or Repaired ( )
y
at / (7‘1, err t J t t-4 v
has been installed ien accordance with the provisions of TITLE 5 of The tag Environmental Code as described in
the application for Disposal Works Construction Permit No. /.5 dated _.�2,-. - / `/ �
THE ISSUANCE OF THIS CERTIFICATE SHALL NOT BE CONSTRUED AS A GUARANTEE THAT THE
SYSTEM WILL FUNCTION SATISFACTORY.
DATE _ if/ c/7 i Inspector
•
No V.y_�::z.=-::-.
THE COMMONWEALTH OF MASSACHUSETTS
BOARD OF HE*LTH
C-1 l+� OF %��l l!(.-w;l."'? L,
113is}ms F2urhs ij trurtin
Permission is hereby granted V e Iii.C-5 i