127 Septic Application Permit & Plans 1991 CHECK OR FILL IN WHERE APPLICABLE
No.. t ft
THE COMMONWEALTH OF MASSACHUSETTS
C/Ty o D�t H.TEALTH
Faa.l.T-1..
Application fat 3Jinpnsttl Works Qlnnstrurfinn jermif
Application is hereby made for a Permit to Construct ( ) or Repair (x) an Individual Sewage Disposal
System at:
n
41.1(.24,
Type of Building
��� )) _
Dwelling—No. of Bedrooms p (/V} 1
Other—Type of Building No of persons Showers ( ) — Cafeteria ( )
Other tee
Design Flow capacity / g�l ions er pge�er n per y tal Bait -r ? gallons.
Septic Tank—Liquid capacity__y._ irt��)%fig �� th Diameter Depth
Disposal Trench—No
net
nstaller
,o.
.4tldress
Address
Size Lot.
Expansion Attic Garbage Grinder
Width Total Length Total leaching area sq. ft
Seepage Pit No l Diameter Depth below inl Total leaching area sq. ft.
Other Distribution box ( ) Dosing tank ( )
Percolation Test Results Performed by �G. . O Date
Test Pit No. 1 p( minutes per inch Depth of Test Pit . Depth to ground water. L�
Test Pit No. 2 minutes per inch Depth of Test Pit Depth to ground
Description of Soil /eF
Nature o PIA r Alter tions A -wer when applicable N
hFF . if) rat.4.i ie = b sti
Agreement: V 2ti it I S t. SNIT 1•.;
The undersigned agrees to install the aforedescribed Individual Sewage Disposal Syste �. cord 'e 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 be ii issued by the bard of health
Application Approved By
Application Disapproved for the following reasons'
Permit No
Date
Issued.
Daze
THE COMMONWEALTH OF MASSACHUSETTS
BOARD OF HEAL
OF /V/"
H
rriifirair of (gumption
THIS TS T'0 ('ER3'Y>;Y, Th he Individual :wage Disposal System constructed ( ) or Repaired (k)
by l� °t 4d2
at
has been installed in accordance wYth tit rovisions of TITLE ?,of Th7 State Sanitary Co e as described in the
application for Disposal Works Construction Permit No % dated.s. S 7?/
THE ISSUANCE OF THIS CERTIFICATE SHALL NOT BE CONSTRUED AS A GUARANTEE AT THE
SYSTEM WILL n/iwN�rJ ION 5 TISFACTORY. c (�
DATE <-1� a / / 7 Inspector
No
/4 y1
Permission
to Construct
at No
as shown on the
DATE
THE COMMONWEALTH OF MASSACHUSETTS
BOARD OF HEALTH
or Me-
is hereby granted
or Repair (x,). an Individual SewagZpisposal System
let
s
J." / Street /
application for Disposal Works Cohstruction Permit N� Da
FEE
fan-Ilrtmii
.di'G t /91/
FORM 1255 HOBBS & WARREN. INC.. PUBLISHERS
Board of Health
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