125 Application & Permit 1970 No 175"
THE COMMONWEALTH OF MASSACH t1SETTS
Fee
BOARD�f9OF� HEALTH
�t G
Appliratinii fur t;
Disposal in'nrU /
s knnstr inn 1rrmit
or Repair Y an Individual
Application is hereby made for a Permit to Construct ( ) p ( ) age Disposal
System at•
i i r LrJxliey Addms
or Lot No.
Address
Address
Type of Building Size Lot Sq. feet
Dwelling—No. of Bedrooms Expansion Attic ( ) Garbage Grinder ( )
Other—Type of Building No. of persons Showers ( ) — Cafeteria ( )
Other fixtures
Design Flow gallons per person per day. Total daily flow gallons.
Septic Tank—Liquid capacity gallons Length Width Diameter Depth
Disposal Trench—No. Width Total Length Total leaching area sq. ft.
Seepage Pit No Diameter Depth below inlet Total leaching area sq. ft.
Other Distribution box ( ) Dosing tank ( )
Percolation Test Results Performed by Date
Test Pit No. 1 minutes per inch Depth of Test Pit Depth to ground water
Test Pit No. 2 minutes per inch Depth of Test Pit Depth to ground water
Description of Soil
Nature of Repairs or Alterations—Answer when applicable..Cite. . . . X"�" �F"C)C1 Nit
Agreement:
The undersigned agrees to install the aforedescribed Individual Sewage Disposal System in accordance with
the provisions of Article NI of the State Sanitary Code—The undersigned further agrees not to place the system in
operation until a Certificate of Compliance has be issued by the bo rd of health.
Signet'
Application Approved By
Sewage
Disapproved for the following reasons'
131:r
..L4.7
Darr
Permit No 3 7-5—
THE COMMONWEALTH OF MASSACHUSETTS
BOARD OF HEALTH
tlik. OF 1
trfifiraft of Qlntii}iliattrt
THIS IS Q CERTIFY, That the Individual Sewage Disposal System constructed ( ) or Repaired (' )
by aid:. -9 N-
.
t'
t .::......:..:... rn.::.: _ati
z
a :
i
has been installed in accbtdance with the provisions of Article XI of The State Sanitary Code as described in the
application for Disposal Works Construction Permit No 2 dated-_ (:{..¢£r'L..::..5:..{: .1./
THE ISSUANCE OF THIS CERTIFICATE SHALL NOT BE CONSTRUED AS A GUARANTEE THAT THE
SYSTEM WILL FUNCTION SATISFACTORY.
DATE ' r Inspector .t.:(.: r 24/__7.nEt
Installer
No
THE COMMONWEALTH OF MASSACHUSETTS
BOARD OF HEALTH
OF
ilispnsal i.i,arks Qinnsfrurtinn tirrinit
Permission is hereby granted....
to Construct ( ) or Repair ( n Individual Sewage Disposal System
at No
FEE
Street
as shown on the application for Disposal Works Construction Permit No Dated
Board of Health
DATE
ffORM 1255 HOBBS a WARREN. INC.. PUBLISHERS