12 Application & Permit 1968 THE COMMONWEALTH OF MASSACHUSETTS
BOARD OF HEALTH
OF ..:,y i„ CcH
Fsa..__.._
Application for Elispnsnl (hunstrurttnn Permit
Application is hereby made for a Permit to Construct ( ) or Repair (K art Individual Sewage Disposal
system at:
{i. tion I C>{a n.
Installer
or Lot No.
'ype of Building
Dwelling—No. of Bedrooms
Other—Type of Building
Other fixtures
)esign Flow gallons
Septic Tank—Liquid capacity gallons
)isposal Trench—No. Width
Seepage Pit No Diameter
Address
Expansion Attic (
No. of persons
Address
Size Lot Sq. feet
Garbage Grinder ( )
Showers ( ) — Cafeteria ( )
Dther Distribution box (
Percolation Test Results
Test Pit No. 1
Test Pit No. 2
Description of Soil
per person per day. Total daily flow gallons.
Length Width Diameter Depth
Total Length Total leaching area sq. ft.
Depth below inlet Total leaching area sq. ft.
) Dosing tank ( )
Performed by Date
minutes per inch Depth of Test Pit Depth to ground water
minutes per inch Depth of Test Pit Depth to ground water
Nature of Repairs or Alterations—Answer when applicable . ..GC I.-s-f .<cra-eA . .QOJ '12I Letak
Agreement:
The undersigned agrees to install the aforedescrihed Individual Sewage Disposal System in accordance with
the provisions of Article XI of the State Sanitary Code—The undersigned further agrees not to place the system in
operation until a Certificate of Compliance has been issued by the board of health.
Signed
Application Approved By tfir " `F nom `s1
Application Disapproved for the following reasons
7/.
%„r n t-k,t14F
e
Permit No
Issued i 't
Date
THE COMMONWEALTH OF MASSACHUSETTS
BOARD OF HEALTH
11 G OF /Lea" �..
Tertiftratr of f nmplianrr
THIS IS TO CERTIFY, That the Individual Sewage Disposal System constructed ( ) or Repaired ('/
by .,`j1st !:-., .,_ c�Lc.n.:.u.fr9
at ai r ,'•:F.LrL ,�..
has been installed id-accordance with the provisions of Article XI of The State Sanitary Code as described in the
application for Disposal Works Construction Permit No 11.a2- dated_!L—.}_L(__/_JEX
THE ISSUANCE OF THIS CERTIFICATE SHALL NOT BE CONSTRUED AS A GUARANTEE THAT THE
SYSTEM WILL FUNCTION SATISFACTORY.
DATE � ' � -�._..d 11E ^� Inspector...._...Y4�..G..C.,..{...:A.l.!:zt:4.tt'-ay
Installer
No / :Li
THE COMMONWEALTH OF MASSACHUSETTS
BOARD OF HEALTH
OF .I- r
FEE
Qispenal_- Narks Qtnnstrurtian ¥ermit
Permission is hereby granted./- .ir -f t fc ..L`ry
M Construct ( ) or Repair (✓) an Individual Sewage Disposal Systei/i
it No i v'... ,:,rt.'.:;,m,d /-¢
(.1 Street
is shown on the application for Disposal Works Construction Permit No *).:-.ai.. Dated t- /‘....L.2L:.:F
DATE
'ORM 1255 HOBBS 8 WARREN. INC.. PUBLISHERS
°bard of Health