35 Application & Permit 1988 No....3 —/1
THE COMMONWEALTH OF MASSACHUSETTS
BOARD 9q HEALTH
/own OF (lttNPE 4
Appliratinu fur 3dinpusai Narks fnnnstrurtinn ljrrmit
Application is hereby made for a Permit to Construct ( ) or Repair (51{l an Individual Sewage Disposal
System at:
3S.Sprr SI
f. . . Leeds
t✓1Ct drrs
L er /1i .% :Z fox vvr bp/i BrF i#s 6u zs
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Owner
Address
Installer Address
Type of Building Size Lot / DOO —Sq_,`feet
Dwelling—No. of Bedrooms .3 Expansion Attic ( ) Garbage Grinder O e
Other—Type of Building No. of persons Showers ( ) — Cafeteria ( )
Other fixtures yam.
Design Flow .SS gallons per person per day. Total daily flow a...rr gallons.
Septic Tank—Liquid capacitye.C.gallons Length Width Diameter Depth
Disposal Trench--No. Width Total Length Total leaching area sq.sq. ft.
Seepage Pit No / Diameter.-.S Depth below inlet Total leaching area,.Vi, sq. ft.
Other Distribution box ( ) Dosi�Y�gn ( / _
Percolation Test Results Performed by"f� _.g.�P/Oh(rrre _.._Rs..._... Date..Z—a—���,) g'
Test Pit No. 1...S.._minutes per inch Depth of Test Pit.. y Depth to ground wale (.. ikd d
Test Pit No. 2 minutes per inch Depth of Test Pit — Depth to ground water ,Wet�SeJu
Description of S it H..2L:C. tre 4rll 6ad_C -r �{r aze #.aany £
ctlable_ J / f
Nature of Repairs or Alts`do - nswer when applicable �-n/DSCQ.-5i5{Cru--_AO t5Cieect
e tSlu/ kvil e44 SASi or. PP
Agreement:
The undersigned agrees to install the aforedescribed Individual Sewage Disposal System in accordance with
the provisions of TITLE 5 of the State Sanitary Code—The undersigned further agrees not to place the system in
operation until a Certificate of Compliance has been issu-d by the board of heal h.
w+t a .. az r/01&b
Application Approved 13y
Application Disapproved for the follow ;g reason
Sig
flt
Permit No
Data
Issued
Data
THE COMMONWEALTH OF MASSACHUSETTS
BOARD OF HEALTH /
OF
kirrtifirotr of Tons ianrr
THIS IS TO CERTIFY, That the Individual Sewage Disposal System constructed for Repaired (1/4,C)
by..t44 e..Xs! reee
at .
nstmle
has been instilled in ac. rdance the provisions of TITi le State Sanitary Coe 3s scribed in the
application for Disposal Works straction Permit No dated_.o7(.Se pi
THE ISSUANCE OF THIS CERTIFICATE SHALL NOT BE CONSTRUED AS A GUARANTEE THAT THE
SYSTEM WILL UNCTION SA/TISFp`�CDORY.
DATE �
-x-� _ - _ /X //(Q Inspector � - L"�'�
THE COMMONWEALTH OF MASSACHUSETTS
BOARD OF HEALTH
OF -
No
Disposal ilinrkn Otnnntrnriinn 4lrrmit
Permission is hereby granted
FEE
to Construct ( ) or Repair ( ) an Individual Sewage Disposal System
at No
street
as shown on the application for Disposal Works Construction Permit No Dated
Board of Health
DATE
FORM 1255 HOBBS & WARREN. INC.. PUELISHERS