35-118 (4) tnstaiier
� Type of Building Size Lot---ZO.j-G'_Q.6.....Sq. feet
U Dwelling—No. of Bedrooms---............... ----------------___---Expansion Attic ( ) Garbage Grinder (►+o)
Other—Type of Building ____________________________ No. of persons_________._______---_--___ Showers ( ) — Cafeteria ( )
GaOther fixtures _____________________________-------------------------------------------------------------
W
Design Flow...............SS 5.....................gallons per person per day. Total daily flow_-_-_--__-__�3_0.--------------------gallons.
WSeptic Tank—Liquid capacity>S_AQo_gallons Length--/Q4"___ `�'idth__E�_".____ Diameter.............._ Depth_�Y''_--
Disposal Trench--No_ ___________________- Width_______._-_-__-_-___ Total Length-----------------_.. Total leaching area_---_-..--_-_-------sq. ft.
W -
Seepage Pit No--------.--._-__.- Diameter/_w,46-e#e,5. Depth below inlet------- Total leaching area.xQ_4-f.'j.SLsq. ft.
Other Distribution box (rV) Dosing tank ( )
a �1®
���Percolation Test Results Performed :=-4T-S- --------------_ Date_.... _ ______._----__ �1
a Test Pit No. I...... __-minutes per inch Depth of Test Pit..._43P---------- Depth to ground waterAk)!!! t47`X—&
(s, Test Pit No. 2_...<.Q..._minutes per inch Depth of Test Pit--- ........ Depth to ground water.jOANrZ AT)o .8-",
----------------------•----
D Description of Soil_. I Q r�`�` �. T°�P ? �.._y.�'ri�`"-./t?? _`__.c !.��'. ' ZL------------------------------
V ---- a----0 f,=, ' ► . .
w -------------------- --------- -------'- --------------------------'-'----------------------------------------------------------" --------- ------- ------------------------------------------------
VNature of Repairs or Alterations—Answer when applicable.__________----------------------_---------------------_________________________...............
---.----• ---•--------•-- ------------•-•------------------------•----------------------------------- ---------------------------------------------------------------.•-----------....................
Agreement:
'_1
T , r v,.
ed agrees to install the aforedescribed Individual Sewage Disposal System in accordance with
z�. r 3 ,.
the @`� � � 5 of the State Sanitary Code— The undersigned further agrees not to place the system in
0 on until a cate of Compliance has been issued by the board of health.
!C`;'t �a.
o >
Signed......................................................................................
_ .�F_ Date
p 'ca lArov Y - ----•-•------------------••--•----------•--------------------------------------
------------------------------------•-°
Date
Aphe following reasons------------------------------------------------------------------------------------------ -----------_..
`Sd NAL
,.g.r d_______________________________________________________________________________________________________________________________________________
f
Date
PermitNo------------------- ----------------------- Issued------------------------------.......------------------
Date
THE COMMONWEALTH OF MASSACHUSETTS
BOARD OF HEALTH
.......T O-W."°.................OF.....;JVp.M7.rA.,1,^ -?U ......................
Trrtgf iratr of Tomptionre
THIS IS TO CERTIFY, That the Individual Sewage Disposal System constructed ('✓j or Repaired ( )
by ------------------------------------ ---------•-----------------------------------------•-------------------------------------------------
Installer
at l)JZ W_,�, n� k' ------------------••-----------
has been installed in accordance with the provisions of TI iT iy`: j of The State Sanitary Code as described in the
application for Disposal Works Construction Permit No----------------------------------------- dated-------.-_..._____-_._____---------------
THE ISSUANCE OF THIS CERTIFICATE SHALL NOT BE CONSTRUED AS A GUARANTEE THAT THE
SYSTEM WILL FUNCTION SATISFACTORY.
DATE--•-------------------------•----------•------------------------------------.--- Inspector....................................................................................
THE COMMONWEALTH OF MASSACHUSETTS
BOARD OF HEALTH
.........773 .............oF. /IIC? "N°,AM_P o�J ...-----...-•---.......
No..----- ---••-------..-- FEE------------------------
Diaposal Eorbi T�ostrurtion rrmit
Permission is hereby granted--------KC2b - - --- .............................................................
to Construct ( vJ or Repair ( ) an Individual Sewage Disposal System
atNo-----------------------X REV" ........ ez_Y.E..-----•----------------------- ----------------'•----------------------------------------__.----------------------
Street
as shown on the application for Disposal s't'orks Construction Permit No_____________________ Dated..........................................
---••--•-------••------------- ....... -------------------- ------------............-----------
Board of Health
DATE--------------------------------------------------------------------------------
FORM 1255 HOBBS & WARREN, INC.. PUBLISHERS