623 Septic Application Permit & Compliance 1999 N
CHECK OR FILL IN WHERE APPLICABLE
No 3/- 4
THE COMMONWEALTH OF MASSACHUSETTS
BOARD OF HEALTH
OF
Application for Dispostdl
rr
nrka Qlutwtruction Vrrmit
Application is hereby nude for a Permit to Construct ( ) or Repair ( ) an Individual Sewage Disposal
System at:
Location?Addre65
.t o.lze�T_ .$ 4 fnV ll�L/t zzT
or Lot No.
./7/.J c 2 c/ti, c— ez- 17L@r(/c,Ls&1L.. Address
Installer Address
Type of Building Size Lot Sq. feet
Dwelling—No. of Bedrooms Expansion Attic ( ) Garbage Grinder ( )
Other—Type of Building lint/4 No. of persons .2- Showers ( / ) — Cafeteria ( )
Other fixtures /
Design Flow gallons per person per day. Total daily flow gallons.
Septic Tank—Liquid capacity gallons Length Width Diameter Depth
Disposal Trench--No. Width Total Length Total leaching area sq. ft.
Seepage Pit No Diameter Depth below inlet Total leaching area. sq. ft.
Other Distribution box ( ) Dosing tank ( )
Percolation Test Results Performed by Date
Test Pit No. I minutes per inch Depth of Test Pit Depth to ground water
Test Pit No. 2 minutes per inch Depth of Test Pit Depth to ground water
Description of Soil
Nature of[Tjepairj,or Alteratiogs s r n a table
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 ssued by the board of health.
p / n. 4.�
Application Approved II y yl.(>�SP..
n.
filyned..
Application Disapproved for the following reasons•
Permit No
Issued
Date
i 'b� 4(1�
THE COMMONWEALTH OF MASSACHUSETTS
BOARD OF HEATH
OF. Al ( J
&I-Windt of Tempt' nrr
by THI T1) 1 FY, the Inuividua Sewage Disposal Sistem cgns ryctegi 141.14gpai
rtiettiVektied
at
ba-3 L...{.NI____ Installer
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 ,S!" f.. dated ��'�✓,laF lj
THE ISSUANCE OF THIS SFAICATE SHALL NOT BE CONSTRUED A NT THAT THE
SYSTEM WILL FUNCTION SATISFACTORY.
DATE 7 — 7 Inspector
THE COMMONWEALTH OF MASSACHUSETTS
BOARD OF HEALTH
OF
jid r/.10
ADD`
Fax
Oise ors t ns ion jrrmit
Permission is hereby granted
to Construct ( ) or Repay (14 an IndiaJ' '�/ Sewage Disposal System
at No ea-3 I'IlE7 � .t!.`:Zx
street
as shown on the application for Disposal Works Construction Permit No."4-9 _
DATE
FORM 1255 A. ULKIN. BOSTON
26
f
Boaetl of