46 application and permit •
CHECK OR FILL IN WHERE APPLICABLE
Faa.crL..._...—
THE COMMONWEALTH OF MASSACHUSETTS
BOARD OF HEALTH
OE_..,\&? ft Ali rir +O.1"I.
ration fur flinpnnal a nrks Qlnnntrnrtinn f rrmit
Application is hereby made for a Permit to Construct
System at:
3_ ? �Zf2 A&tlr's Altai
Owner
Installer
Type of Building
Dwelling—No. of Bedrooms
i
Other—Type of Building lth'3@�x. 1�A11.... No.
Other fixtures
( to an Individual Sewage Disposal
C 46
I/L, or rot Nn.
a�iA..
/ Address
Address
Size Lot_it' Sq. feet
Expansion Attic ( ) Garbage Grinder (✓p
of persons V Showers ( ) — Cafeteria ( )
Design Flow h?.
Septic Tank—Liquid capacity
Disposal Trench—No
Seepage Pit No
Other Distribution box
Percolation Test Results
Test Pit No. I
Test Pit No. 2
Description of Soil
gallons per person per day. Total daily flow "a1 gallons.
gallons Length Width Diameter Depth
Width -4 - Total Length.. ,:3'b ' Total leaching area.._/i 5t._i2.sq. ft.
Diameter Depth below inlet Total leaching area sq. ft.
Dosing tank ( ) 0 ,tt1 1
Performed by ' iti•--"*�f"1-'%:"` '� Date %Y'� yft T
minutes per inch Depth of 'ICS Pc-1/0 1. Depth to ground water__.idI,l4
minutes per inch Depth of Test Pit Depth to ground water
Cay ,u 9 , .
Nature of Repairs or Alterati ns—Answer when applicable.. xli7(-.IC.l=
HRl=�1 Q1v.b.y
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 issued by the board of health.
Si
Application Approved By
r'//' 3' 4'/
Application Disapproved for the following reasons'
Permit No
Date
Issued.
by
THE COMMONWEALTH OF MASSACHUSETTS
BOARD OF HEALTH
OF
«trditiratr of (itomplianrr
THIS IS TO CERTIFY, That the Individual Sewage Disposal System constructed ( ) or Repaired ( )
Installer
at
has been installed in accordance with the provisions of TITLE 5 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
No 3o- `1N
THE COMMONWEALTH OF MASSACHUSETTS
%1 BOARD OF HEALTH
Disposal riinks fdnnoir n/Permit
.Permission is hereby granted.. &t6L.d
to Construct,4 or Repair (X an Individual Sewage Dispo ystem
at No ...C _,r:..rt It r
as shown on the application for Disposa
DATE
a_ ei5
FORM 1255 A. M. iULKIN. BOSTON
St
nstruction Per
'/.) I /i4
Board of Health