964 Septic Appications Permits & Compliance No S�{
CHECK OR FILL IN WHERE APPLICABLE
THE COMMONWEALTH OF MASSACHUSETTS
BOARD OF HEALTH
OF
Application f aispnsnl i l arks (ln44struttion 1.rrmit
Application is hereby made for a Permit to Construct ( ) or Repair (V) an Individual Sewage Disposal
System at S 4
Azt
i�t ion.Addre
V_
ler
Type of Building
Dwelling—No. of Bedroom
Other—Type of Building
Other fixtures
Design Flow .5—S
Septic Tank—Liquid capaa it y
Disposal Trench No.
Pit No
Other Distribution box ( ) Dosing tank ( ) Date
Percolation Test Results Performed by
Test Pit No. 1 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
6 _ Address
Address
Size Lot Sq. feet
3 Expansion Attic ( ) Garbage Grinder (/\')
Showers ( ) — Cafeteria ( )
No. of persons
gallons per person per day. Total daily flow 3..3 O gallons.
gallons Length Width Diameter eBfyss.
— o. Width a r Total Length 3 0... Total leaching area.. �J sq. ft.
Diameter Depth below inlet Total leaching area sq. ft.
Description of Soil
a4€
Nature of RRepa �ationswer hen a licabl
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 Comeliance has been issued by the board of
�
Application Approved By i�G i
-- --
Application Disapproved for the following reasons'
Permit No
Dale
Date
THE COMMONWEALTH OF MASSACHUSETTS
BOARD OF HEALTH
OF fLi.. `.�. .
(artificer of (gumption('
Sqw, enDtsposal System constructed ( ) or Repaired (k)
THIS IS TO_JCER%IFY, T M theindividq
by -
C../--.a.
at
has been installed in accordance with the provisions of TITLE j of The State Sanitary 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
rtya
No
THE COMMONWEALTH OF MASSACHUSETTS
BOARD OF HEALTH
/ ' .
OF ,.
Disposal
crl
ruts (lbnnstrixrtiunyrrmit
FEE
Permission is hereby granted
to Construct (r,), of Repaij S X) an IndividuallSewage Disposal System
at No P% • street
as shown on the application for Disposal Works Construction Permit No._u Dated
DATE
/
FORM 1255 A. M. SNLKIN. INC.. BOSTON
Board of Health
CHECK OR FILL IN WHERE APPLICABLE
No
I
THE COMMONWEALTH OF MASSACHUSETTS
BOARD OF HEALTH
- _ of - . 4. °tip
)
Alfpliratinn fur Binpnsttt rF nrkn Cnnnntrurtinn j rrmit
Application is hereby made for a Permit to Construct (t.�'or Repair ( ) an Individual Sewage Disposal
System at:
it
nit &Atrtee! r..3/ .
LocatrnrAdcipress
Oy/Aer
Installer
Type of Building
Dwelling—No. of Bedrooms
Other—Type of Building No. of persons
Other fixtures
or tot vo. = _
Addressi�r�.
r
Address
Size Lot 3' 5f ._Sq. feet
Expansion Attic ( ) Garbage Grinder (l( )
Showers ( ) — Cafeteria ( )
f 1 C _ gallons per fy. Total daily flow °( 9 gallons.
Design Flow Width Diameter Depth
Disposal T `L.igmd capacity./St. g=dlons Length -� L2 sq. ft.
Disposal —No. - Width 1. Total Length >'-O ' Total leaching area
Seepage Pit No Diameter Depth below inlet Total leaching area sq. ft.
Other Distribution box ( ) Dosing tank ( ), rT f' -vC -f K,{"...,., Date S / .5 / £ �'-
Percolation Test Results Performed by p '"' / yL, "
Test Pit No I minutes per inch Depth of Test Pit G Depth to ground waterE
Test Pit No. 2 minutes per inch Depth of Test Pit Depth g
�nf
Description of Soil.. 'A S`µ`4-o
Nature of Repairs or Alterations—Answer when applicable
Agreement:
The undersigned agrees to install the aforedescribed Individual Sewage Disposal System
the provisions of TITLE 5 of the State Sanitary Code —The undersigned further agrees not to
operation until a Certificate of Compliance has bOn issued by the board of health.
)/gigne� A-c-n-5/i i%yi'' i
t€r P
Application Approved By /� `"�%' l
,
Application Disapproved for the following reasons
in accordance with
place the system in
7;ti xv
� Date
Permit No
Issued-
Date
S
by
at s- The State Sanitary Code as desced in the
has been installed in accordance with the provisions of TITIi 5 dated =21)-1 de d
application for Disposal Works Construction Permit No..Z_�
THE ISSUANCE OF THIS CERTIFICATE SHALL NOT BE CONSTRUE AS G A ANT E THAT THE
SYSTEM WILL F�NCTIIONN. IATI FFAI TORY. Inspector
DATE ," ij /
THE COMMONWEALTH OF MASSACHUSETTS
BOARD OF HEALTH
THE COMMONWEALTH OF MASSACHUSETTS
BOARD t F HE TH
. ...._._.._OF
Cnrrtifiratr of @imnpr ore
the Individual Sewage Disposal System constructed ( or Repaired ( )
THIS IS T E 'TIFY
f
No ` 17 l3ihpootti rk; kinnofrfulio t front
. i ranted � Y•
Permission is hereby g ,
to Construct ( ) or Repair. ) an Individual Sewage Disposal System L� (`
at No .vce-1" f_ ._st. � .�1. . 7
-?4 {D�a�ted —
as shown on the application for Disposal Works Construction Perm No {AAA
JJ (J3a rd of Health
DATE ,e--9/31/..0 y
FORM 1255 M. SULKIN, INC., BOSTON