1157 Application & Permit 1982 R.
HUN,
0
THE COMMONWEALTH OF MASSACHUSETTS
BOARD OF HEALTH
Ci b; OF . . >1crtharittpon
1ppl ration for flhq nstti Works Cnnnntrurtinn jrrmit
Application is hereby made for a Permit to Construct ( X) or Repair ( ) an Individual Sewage Disposal
pSystem at:
✓✓✓����/N// Pliara ae.'road or Lot No.
Lwatina-Address
73...Re3 DA ava�Placenca..._...
NM
{4 a-J1 el
•a installer G Size LOC1..627...Acrat .SCet
G Type of Building Expansion Attic ( ) Garbage Grim:
Crf�)
U Dwelling—No. of Bedrooms 4 P
', Other—Type of Building No. of persons Showers ( ) — Cafeteria ( )
Pi Other fixtures gallons
G Design Flow S5 gallons per person per day. Total daily flow.-44. .Y--j.;9ef}6 )
W \'idth Diameter Depth
a Septic Tank—Liquid capacity gallons Length _
Z. Disposal Trench—No..._2 Width 2 r Total Length 3e' Total leachir((; .City 72A1_gpd
ill
• Seepage Pit No Diameter Depth below inlet Total leaching area sq. ft.
Other Distribution box (x ) Dosing tank ( ) Date
z by Dan -n lie r--kssot.
Percolation Test Results Performed b
a7 Test Pit No. 1..2.,E minutes per inch Depth of Test Pit Vert Depth to ground water...None
U, Test Pit No. 2._z...p.....minutes per inch Depth of Test Pit 9` Depth to ground water..ti 3a
O Description of Soil
U
1n..{TS 32.n...-tilt 8-'-t a..sa+s2 gravel
9t`--OTB G'-6°-'sand & gravel Ills- clay
Nature of Repairs or Alterations—Answer when applicable
Agreement:
The undersigned agrees to install the aforedescribed Individual Sewage Disposal System
the provisions of TiTia. 5 of the State Sanitary Code—The undersigned further agrees not to
ed by the boardd lth.
operation until a Certificate of Compliance has been
Sign
Application Approved By
Application Disapproved for the following reasons'
in accordance with
place the system in
Permit No
a -d )--
by
at
has been installed in accord e with tl e provisions of TITLE 5 of The State Sanitary Code s d scribed in the
application for Disposal Works Construction Permit No 0'._-e — dated tats
THE ISSUANCE OF THIS CERTIFICATE SHALL NOT BE CONSTRUED AS A GUARANTEE THAT THE
e
THE COMMONWEALTH OF MASSACHUSETTS
BOARD OF IlEALTH
OF . F1 ( 4 o-'1
rrtifirate of Tomplianrt
Sewage Disposal System constructed ( /4--151:-Repaired
THIS IS TO CERT( Y, Tha
SYSTEM WILL FUNC ION SATISFACTORY.
DATE el457)-
No
Inspector
THE COMMONWEALTH OF MASSACHUSETTS
BOARR OF HEALTH
OF
{
1 isponi orkf..01 strurtian Permit
Permission iss hereby granted..r:.S `ieval"1
to Construct r ) or Repair.. )-an Individual Sewap�7Djsposal stem
at No )°c-r.�l., .,..u.�,. i^.'e'l. 1. .-
Street
as shown on the application for Disposal Works Construction Permit No.
DATE .F/ld %Q°i_.
FORM 1255 HOBBS & WARREN. INC.. PUBLISHERS
r " 1/4
FEtp •GZ
_ft ., '� -�
Dated
Board of Health