6 Applications & Permit 1974 THE COMMONWEALTH OF MASSACHUSETTS
OARD OF HEALTH
OF
Applirtttinn -fur 13- i ipnsttl Ilinrkz
FEE
nnstrurtlnn Permit
tpplication is hereby made for a Permit to Construct ( ) or Repair ('an lndit idual Sewage Disposal
n at:
Instal:or
of Building
)welling No. of Bedrooms
)ther—Type of Building
Other fixtures
n Flow gallons
Tnd:—Liquid capacity gallons
sal Trench—No. Width
ige Pit No Diameter
Dosing tank ( )
Performed by Date
minutes per inch Depth of Test Pit Depth to ground watr'
minutes per inch Depth of Test Pit Depth to ground water
or Lot No.
Aa ltess
Expansion Attic (
No
Aedrea
Size Lot Sq. feet
Garbage Grinder ( )
of pi)son) Showers ( ) — Cafeteria ( )
Distribution box (
Jation Test Results
Lest Pit No. 1
Pest Pit No. 2
iption of Soil
per person per day. 'Total daily (low gallon..
Length With-_ Diameter Depti, -
Total Length Total leaching aroma sq_ ft.
Depth below inlet Total leaching are.: al. ti.
re of Repairs or Alterations—Answer when applicable.5Qy? u-u'--._u-y.-k- i -
emenc
The undersigned agrees to install the afaredescrihed Individual Sewage Disposal System in accordance with
rovisions of Article AI of the State Sanitary Code— The undersigned further agrees not to place the system in
ition until a Certificate of Compliance has been issued by t)ie boa of health.
Signed_r, X4'4 1- P=te
ication Approved By .��
ication Disapproved for the following reasons'
I C.
Permit No._o.2.-3 Q
Oatc
Issued
Date
THE COMMONWEALTH OF MASSACHUSETTS
BOARD OF HEALTH
OF
OCertifiraie of Qlnmplianre
PHIS IS TO CERTIFY, That the Individual Sewage Disposal System constructed (
) or Repaired (
Installer
:,en installed in accordance with the provisions of Article XI of The State Sanitary Code as described in the
xtion for Disposal Works Construction Permit No__.____.. ______. dated
THE ISSUANCE OF THIS CERTIFICATE SHALL NOT BE CONSTRUED AS A GUARANTEE THAT THE
'EM WILL FUNCTION SATISFACTORY.
E Inspector
THE COMMONWEALTH OF MASSACHUSETTS
BOARD OF HFFALTH
OF t f
FEE'A '
Ji,poial.Work&,(pnp,trur#iou Permit
'ermission is hereby granted, _ "t
nstruct ( ) or Repair (i ) au Individual Sewage Disport System
awn on the appl
stint
tion for Disposal Works Construction _Permit No ^' Dated
1255 HOSES & WARREN. INC.. PUBLISHERS
i
tst
Board of Health
v