508 Application & Permit 1993 No.?
THE COMMONWEALTH OF MASSACHUSETTS
Fa>if ' o
BOARD OF HEALT�
C l7 OF /Jtn're fJT'
Application for finponal illurkn CEnnntrurtinn rrmit
Application is hereby made for a Permit to Construct ( ) or Repair (4j an Individual Sewage Disposal
System at:
0 0B Sy»Jctsre RbA0
A ,, t1 gar A-e} ekr
9 "�sl-
C. 'Fluty- I �iSe
Installer
Type of Building
Dwelling—No. of Bedrooms 'f..7 Expansion Attic
Other—Type of Building No. of persons
Other fixtures
CD 7 S 4r
Address
Address
Size Lot
Garbage Grinder (yrs
Showers ( ) — Cafeteria ( )
.ee:fSq. feet _
Design Flow 1.6 O gallons per person per day. Total dal
Septic Tank—Liquid capacity.J02gallons Length /P Width
Disposal Trench No
Seepage Pit No Diameter Depth below inlet
Other Distribution box ( ) Dosing tank �1t [(y�
Percolation Test Results Performed by
Test Test Pit No. 1_..minutes per inch Depth of Test Pit
Test Pit No. 2 minutes per inch Depth of Test Pit
f
daily flow t[..RS-__gallons
s
Diameter Deppth...V•J q
Total leaching area l.J� sq. ft. /3A
Total leaching ar ��.` q. ft. SaDbs
Width !.fl` Total Length /' t
3
A51(`
Description of Soil
•Date
Depth to gm
Depth to gr
Come& VAivi3 +0 deride& StAt.o:
Ain t
Y��Env
Nature of Repairs or Alterations—Answer when applicable J�..
%EF=L.ACE
Agreement'.
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 issue, by the board of health.
li
Application Approved By
Application Disapproved for the following reasons:
Permit No. Issued
THE COMMONWEALTH OF MASSACHUSETTS
BOARD OF HE LTH
Tertifirde of Cnampliat4e
THIS IS TO CERTIFY,That the Individual Sewage Disposal System constructed ( ) or Repaired ( )
by V, Lity j V 1 t t fv 4 ct V li '{C r S
at R(CS. .r..+9 -Er) 'el ina- pJ
has been installed in accordancrj with the provisions of TITLE 5 of The State Environmental Code as described in
the cat on for Disposal Works Construction Permit No. _ q C Z dated - /-� /s7,
THE
ISSUANCE OF THIS CERTIFICATE SHALL NOT BECONStRl1ED AS A GUARAY4TEETHAT THE
SYSTEM WILL FUNCTI N SATISFACTORY.
DATE 3,./553 Inspector
No I
—2
THE COMMONWEALTH OF MASSACHUSETTS
BOARD OF HEALTH
/ OF L'/-t-7-F!11..b.ka...)4....l..../
Oinpnaal ,r'nth Qtaantrurtian Ihrmit
Permission is hereby granted
:o Construct ( ) or Repair (X) an Individual Sewage Disposal System
I
it No c.e..iy 3C7.{_1,4e.5 Pit Street
is shown on the application for Disposal Works Construction Permit N4.7-)(2 _ Date),_
FEE
DATE T.`-J-cma /.(14 s
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