80 Septic Application & Permit 1997 THE COMMONWEALTH OF MASSACHUSETTS
BOARD OF HEALTH
City OF yO/,l-TNl/2 4. J
Applirntiun fur lispuzal iliurks Tunstrurtiun permit
n is hereby made for a Permit to Construct (t4 or Repair (t/Yan Individual Sewage Disposal
0,5' S//4 /J
50 z .-21- -/e // 2te/d4-,c ,Le/1/i/e/rp4 n/2
SG .0U,2/F,c5 V /.t" a-c-O er U35<f%,•-i nz J J
AA
/ oI. n I Address �...!
. L j - r
o
u Type of Building p Size Lot /�-Y/ST
Dwelling-No. of Bedrooms v/ d Expansion Attic Grinder feet /r
cop F'a (/f�G Garbage Grinder
a, Other-Type of Building,ti3O.£//Ls:a _ No. of persons /r,
M P T// :::,/5.° Showers (/ ) - Cafeteria ( ) $O -,
Other fixtures �(i/L..,fjCi.1./ ,�/ G%.f- �
Act- .5,4TC_t:sP
�• Des'gn Flow �J U ! gallons per person per day. Total daily flow.../lL1..�-J,��, gallons _ .-/
W=Y/jSbjfd741k-Liquid capacity,J/17.Ilgallons Length._/0.'/2 WVidth_.. Diameter
Disposal/Trench osal/Trench-N o � '1 "- lleptqhO^.s i4%s
'.q P Y..t-�C.!.y.... Width lc Total Length__!1�lp.__ Total leaching area_-,/1/-F..V..q. ft.
• Seepage Pit No Diameter Depth below inlet_49 ' Total leaching area sq. ft.
z Other Distribution box (/ ) Dosing,tanlc ( )
.7 Percolation Test Results Performed by_ _ L4L../19CY1f//4/L-(.r?-7 Date 34/////911
1-1 Test Pit No. I...l'0 minutes per inch Depth of Test Pit...s5....... Depth to ground water
W Test Pit No. 2 minutes per inch Depth of Test Pit Depth to ground water
o T/'/-/ 0.-1J-.... :7735cen ...» 5 q o'#c 7 /04'/z 5-S
Description of Soi`ll ./5"--41-0 S/C /. /2-..:V,G?_L. ,-re e~#/ nett...da.' S..N-c1/..CL!<1 Con
U
ral //ZZ —/30 /->?�z Oagfe-sr ..rh-r/<Q cY 5/914-1Q /oreef. -S
to n-L, se: e ' Cz ,yru./.0 /o ye la—/
Nature of Repairs or Alterations-Answer when applicable Ato /le& /(//0 O21-74 12
Agreement:
The undersigned agrees to install the aforedescribed Individual Sewage Disposal System in accordance with
the provisions of TITLE 5 of the State Environmental 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.
Installer
Application Approved By
Application Disapproved for the following rea
Sig
v - 1 0%'.-
1 7 7
Dace
Permit No. _.. Issued
THIS IS TO CERT
by �'y, That the Individual Sewage Disposal System constructed•
THE COMMONWEALTH OF MASSACHUSETTS
C BOARD OF HE TH
OF jL `'
/ Oerttfirttte of Complianee � >�
at C...._ J/C_L'
has been installed in accordance kith the provisions of TITLE 5 of The Stare Environmental Code as described in
the application for Disposal Works Construction Permit No ,Of— /
THE ISSUANCE OF THIS CERTIFICATE SHALL NOT BE CONSTRUED A dGU `-_,E I TH
SYSTEM WILL FUNCTION SATISFACTORY. A GUARANTEE THAT THE
DATE 1 r— ' % > "".
Inspector
or Repaired (V
No 77
Permission is hereby
to Construct
( or Regan. an Irk System
at No Disposal .._.__._
._. G vidim�eµage S stem
as shown on the application for Disposal
THE COMMONWEALTH OF MASSACHUSETTS
BOARD OF HEALTH
)..___.OF
�ffl l marks olt
granted_..___ �r� 'b. rZtrtlAn ,�pra�tt
n �/, /%%
5 <_c>
FEE
Works Construction Permit 1� /
,ems �
DATE _�__ _
FORM 1255 qM SULKIN n�