368 Septic Application & Permit 1972 THE COMMONWEALTH OF MASSACHUSETTS
BOARD OF HEALTH
c,
Application for Disposal rr orks termstrztrtion '39rrntit
Application is hereby made for a Permit to Construct ( ) or Repair (,J an Individual Sewage Disposal
System at: . -
i F fi=
.�........_.. or Lot No.
_...............' 3.,..,......
Location 4.0,Aa .4.. Address
4.FO neT •._.................. ...--_..._......_ Addresss....-'
1�. :n' `` Size Lot._..._....._._...._.Sq. feet Address
WW m.�an�. Garbage Grinder ( )
gal Type of Blinding Ex nsion Attic ( ) — Cafeteria ( )
et O Dwelling—No. of Bedrooms..._...._......._.._.....
gaga.._._ pa
Naai a of Building ._._.._._..__.._._.. No. of persons.................... Showers
Other-Type ._. ._.___..._.._._.._.__._____._.._..gall._..
p, Other fixtures _____.._._._.._._...___._._..._
d ,_"__" ..gallons per person per day. Total daily Slob Diameter
- P" gallons
De th Septic ank—Liqui_____.._. A Ions Length__..._._._ Width.._._._.. � .sq. ft.
W Septic Tank—Liquid capacit}�...a�--gal
g _y
WZ Disposal Trench-No..._._._..._.._Width..___.._.__Total Length.____.__.__. Total leaching area_..
Seepage Pit No...__.._____. Diameter Depth
tank e(th)below inlet...._._....__ Total leaching arm-------..-s9 {`..
Z Other Distribution box ( ) Performed b "" ""'
Percolation Test Results
Y--'-"-"" D th to ground water..................
.] Depth to ground water............... ..
5 Test Pit No. l_'- minutes per inch Depth of Test Pit.... .._._...._ P
1-1[s, Test Pit No. 2..._��---�
O Description of Soil_ ......._...-'--_......_......................._..............._._..._.._....._ .
.._........_...._......_._...
aga. _ .._ _._.._._.......r._.
,, ,,, ,
U.1
-. livabl - _..
U Nature of Repairs or Alterations—Answer when app
.._....._...._.. ......
The undersigned agrees to install the aforedescribed Individual Sewage Disposal System in accordance with
Agreement:the eprovi until a Article XI of Compliance the
e has Sanitary Code e— `bhh the boa 4 of hearther agrees not to place the system in
Signed �fy(} �.^r 1.1 i f :2 ;
n �
Application Approved BY......................
-. - ' '.'�� U -'�"'"""
. a
Application Disapproved for the following reasons:__.__....._...._...._._.._.
Date
Permit No..J..Jv J. _ Issued.... k .ht. _/.17
..114.2.a_._
n: ,
THE COMMONWEALTH OF MASSACHUSETTS
BOARD OF HEALTH
OF
(tertifiratt at Tmnplittnre
THIS IS TO CERTIFY, That the Individual Sewage Disposal System constructed ( ) or Repaired
)
by Installer
at
has been installed in accordance with the provisions of Article XI of The State S nitery Code as described in the
application for Disposal Works Construction Permit No
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
33ispnsal rr arks Qiunstrurtinn Vtrmit
Permission is hereby granted.. .yJ &x,: : i. .,;..'1-•t•"yLzgitt.t
to Construct (f or IWiair fon yt dividua Sewage Disposal System
FEE.: <I :
at No 1144 1144 xtidF..v_�._ry. ...y Street as shown on the application for Disposal Works Construction Permit,.No i Dated
i Buard of Realth ,.
DATE
FORM 1255 HOBBS b WARREN. INC.. PUBLISHERS