595 Applications & Permits THE GOMMON`NEALTH OF M SS^LTH S
EA
T ..
BOARD OF H
7in OF_NQRTHAMF
A.pplictttion for Disposal Thor
ks &Instrnc#inn Permit
or Repair ( ) an Individual Sewage Disposal
pplitation is hereby made for a Permit to Const.uc ( ) ( .
a at:
oca'on -Nddces
Installer
/ Address i8()
. .._............._..............._........ ... U
-- -- Address
._._._. /, 3-. -..S4. feet
Size Lot___.-----
✓)4ES
Garbage Grinder
ansion Attic ( )Showers ( ) — Cafeteria ( )
�7 ._......._.
_ - �yp 1..}._'_..7.. .__..gallons.
.. Total daily flow
-- Diameter Depth-- ---
Diameter
Width___ - -
Total leaching area- - �' ft.
Length sq. ft.
ow inlet . �� Total leaching area
$�PDate- .-.. '/�/ ..
Depth to ground water-/✓
M ' Depth to ground water_fl
Bxp
• of Bunging
No. of Bedrooms Lr o. of perso
Dwelling— - - __.
Other—Type of Building __.
Other fixtures aliens per person per da
ign Flow---------------------------------------- -
- Length i -- allons gt
po Tank—Liquid capacity-LS._-
Total'\o - Width
-
- Diameter-- --- Depth bel
posal Trench- -
page str Ntio x -( Dosing tank )
-_...
tier Distribution box ( ) Performed inc Depth of Tes
rc 1 tton Test Results � er inch
o a minutes p of Test
Test Pit No. 1 es per inch Depth
oil... ..__Sea) .___. ._..
minutes i
Test
Pit \0 2. __.__.--
escription of 5
--- Answer when applicable....... -- - - ..._.
Repairs or Alterations .. ...........................................
._.. -
Qature of Rep ...................
- - ---
_. .........................
- Sewage Disposal System in
system with th
Agreement: The mid- igned further agrees not to place
undersigned agrees it install the tary Code The mid igned further
j of the State Sanitary Code— ,oar of hlt
the provisions ut of TITLE Compliance has been issued by t
operation until a Certificate of amp
�•igni ..4"/ /
dna
h.
o _Y
cl
_ /7
..._. � ate /
Approved By. —.. ----
Applicatio.. APP ._...._.
._____.___
roved (or the fol owing +easans:.
Application Disapp .-„-,_-..
...... ._____._..__.... ..........
_ __..... Issued.-...._..._.._{Dam
_.....
Permit No..-.....'.._
THE COMMONWEALTH FF HEALTH MASSACHUSETTS
BOARD RD
._._...._..
Ct°rioFNoR>"NaMpT .__ .____ - - rani#
Application for l3isposal rc larks &instruction
Repair ( ) an Individual Sewage Disposal
Application is hereby made for a Permit to Construct ( ) or J •rat at: ............_- ....._.....—or Lot e%...
ti -
T L t Add - �� ----
21;..1..r
Size Lot. . . ...
...__.._......,...-- 'm.t,n`r Garbage Grinder rinder(feet
�e of Building __.._.__Expansion Attic ( ) age Gri der ( )
Dwelling—No. of Bedingms__.....-.----..".... -
No. of persons..................... Showers ( ...............
e of Building .-_.__.__.._..._ _ y./ ._gallons.
t
Other fixtures --- Depth_..--- -
gallons per person per day. Total daily ow.77(.4
..... .. _._
._ ci._.- sq.ft.
sign Fiore--.._-_._ o.-capacity 5 Width Length...... . Width. ..._._Total leaching area...._........__
expos e Pit N Liquid tap '
ispage Trench—No..-._..._ Width...._._... Total Length _
eepage Pit No.__._.-.--.-_ Diameter....___.___. Defrrrpth below +det..._.d-� Total leaching Seaa.................
l'��.......
p Dosing tank 1�.:.) Date.-
they Distribution box ( ) t/[fL._..-- water_.---P
Performed u es per inch D. %.1-. . . Depth to ground ��-/U e
ercolast Test Results minutes er inch Depth of Test it..�-I.y. ound water..!-!2- -
Test Pit No. l.-.a:'-"' per
to Test Pit No. 2__...._._._mtnutes p inch Depth of Test +t-� -----""". Depth
Jeunpnon of Soil...............
Nature of Repairs or Alterations—Answer when.applicable
............. _ ......................................
..-.._....__...___._.__.._.-
.._______._..__.- � e Disposal System in accordance with
Agreement: // system in
The undersigned agrees to install the aforedesaibed hnedtnder6gn d further agrees not to place the sy
Issued by the-Iioard,of heglth. _, . �.
the provisions operation until of TITLE 5 of the State e haSanitary Code issued / �;
operation until a Certificate of Compliance has been . ............ ... _.......__.__ Date! _ _+
'Signed_........._......_....
mt.
Application Approved By._......_.....__......._.__. . .........-
Applitation Disapproved for the following reasons: .__._.__._.. - .."..'...."..._.-_..-
f -
Issued.._..............Date Permit No...........___=-
THE COMMONWEALTH OF MASSACHUSETTS
BOARD OF HEALTH
C,I oFNORTHAMPION
ltT)i erlifirate of (ltontpliatut
THIS IS TO -- Y, hat the Individual Sewage Disposal System constructed (X) or Repaired ( )
•------------------------ ------- --- --'-
i-44b t mcadidemacerca:m------- ran
been installed in accordance with t provisions of TITLE 5 f he State Sanitary Code's de sc bed in the
)lication for Disposal Works Construction Pennit No e..* ' dated
THE ISSUANCE OF THIS CERTIFICATE SHALL NOT BE NSTRUED AS A GUARANT AT THE
f STE TEM WILL F7CTIO7riT/BFACTORY.
N --------------------- — ..............................._ Inspector........... ......... .. ..............................._............
THE COMMONWEALTH OF MASSACHUSETTS
BOARD OF HEALTH
WY 0FINORTHANAP10,•N Fa—....:..2........._.
Disposal n grits glonstrtulaut Derotit
Permissionis hereby granted................i.................,..............................................................................................----
r.o Construct (,` ) or Repair ( ) an Individual Seviage Disposal System
It No.................f....... ' , • .
Street ,
as shown on the application for Disposal Works Construction Permit No.................... Dated..........................................
Board of Health
DATE.......................... .................................................
FORM 125 5 A. M. SULIKIN. INC.. BOSTON