1005 Application & Permit 1985 CHECK OR FILL IN WHERE APPLICABLE
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THE COMMONWEALTH OF MASSACHUSETTS
BOARD OF HEALTH
CITY oFNORTHAM.P.IO.N
urka Qtun trurtinn Permit
Applirattnn fur Dispu iat
rr
Application is hereby made for a Permit to Construct
System at:
C '
LcraHaa //
.t.t kArf22
•b
or Repair (rl an Individual Sewage Disposal
VTLot No.
/ pdds
Installer V Address//
Type of Building Size Ldt Sq. feet
Dwelling—No. of Bedrooms Expansion Attic ( ) Garbage Grinder ( )
Other—Type of Building No. of persons Showers ( ) — Cafeteria ( )
Other fixtures
Design Flow gallons per person per day. Total daily flow gallons.
Length Width Diameter Depth
Total Length Total leaching area sq. ft.
Depth below inlet Total leaching area sq. ft.
tank ( )
Septic Tank—Liquid capacity gallons
Disposal Trench—No. Width
Seepage Pit No Diameter
Other Distribution box ( ) Dosing
Percolation Test Results Performed by
Test Pit No. 1 minutes per inch Depth of Test Pit
Test Pit No. 2 minutes per inch Depth of Test Pit
Date
Depth to ground water
Depth to ground water
Description of Soil
N ure`of IRepai7 or �Itertjofl sr-An vverr when.�opl�bk
eement: oy CV if Cn
u
The undersigned agrees to install the aforedescribed Individual Sewage Disposal System in accordance with
the provisions of TITLE S of the State Sanitary Code—The undersigned further agrees not to place the system in
operation until a Certificate of Compliance has been isgued by the board of health.
Application Approved By F-��" " {'
Oat.-
Application Disapproved for the following reasons`/
THE COMMONWEALTH OF MASSACHUSETTS
BOARD OF HEALTH
CITY OF.N.ORTHA.MPT.O.N
Trrtifiratr of Qlnm}Tlittnrr
THIS IS T IFY, ThiNhe IndividuyLtage Disposa]_System constructed ( ) or Repaired (t-
by nnallTh
has been installed in accordance with the provisions of TITLE 5 of The State Sanitary Code as descr ed in the
application for Disposal Works Construction Permit No .7.:. - C % dated #/-_/I 5
THE 4ISSUANCE OF THIS CERTIFICATE SHALL NOT BE CONSTRUED AS A GUAL{ANTEE THAT THE
SYSTEM F�Uy�/NCTION SATISFACTORY.
DATE 7' Li 1125 Inspector
Noc33' X _-
THE COMMONWEALTH OF MASSACHUSETTS
BOARD OF HEALTH
CITY oFNORTHAMP_ION
3�is}TO��l ork01konstrurtinm.
Permission is hereby granted l ^^�-" � ,L.g. Li-se
to Construct ( ) or Repair 257 Individual Sewage Dj)sig•oaal System
at No
f.CZ ...S �'4��: /7—r" ! /
strxr
as shown on the application for Disposal Works Construction Permit Nn-c.,2- < •s I�pterdy" 7
f;( Board of Health
DATE iv / fy ?
FEE ./ ' f V
v
FORM 1255 A. M. ILKiN, IN C.. BOSTON