1192 Applications & Permits CHECK OR FILL IN WHERE APPLICABLE
THE COMMONWEALTH OF MASSACHUSETTS
//�� BOARD OF
l..tZf, of /�8",`t
ALTr1
--11
Fax `7T'_
)ppliratian or i3ispuzat re arks Tunstrurtinn Permit
Application is hereby made for a Permit to Construct ( ) or Repair ( ) an Individual Sewage Disposal
System at:
.. or Lot No.
jfil�.�r....... .cr Fes..ez:.. ... .. .........._._...._.
L1 ... Location Aaa,„
....__�. .t (l p.c f
fa i f 8071; t ,
Address
G /-�t...� Address
Type of Building L. Size Lot Sq. feet
Dwelling—No. of Bedrooms g Expansion Attic ( ) Garbage Grinder ( )
Other—Type of Building No. of persons Showers ( ) — Cafeteria ( )
Other fixtures (
Design Flow SS gallons per person per day. Total daily flow S--g..O,2 gallons.
Septic Tank-Liquid caflocity/..cagallons Length Width Diameter Depth
Disposal Trench—No... CI Width 2:2. Total Length...Z.&_CL... Total leaching area../5!.y.Q.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. 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
Installer
Description of Soil
Nature of Repairs or Alterations—Answer when applicable
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 been issued by the board of health.
ed
Application Approved By �t--��� '1;2 Date
Application Disapproved for the following reasons'
Permit No
Issued_
Data
Date
by
at
has been installed in accordance with the provisions of TITIE 0/5 of The State Sanitary Code de.fi ed in the
{.
application for Disposal Works Construction Permit No .D v dated....- 77-- .�
-- ./ 7'0
THE ISSUANCE OF THIS CERTIFICATE SHALL NOT BE CONSTRUED S A GU A NTEE AT THE
THE COMMONWEALTH OF MASSACHUSETTS
BOARD OF HEAJ..TH
OF
Qlrrtifirate'nf Qlumpli+tnrr
THIS I,S3'Q�CERT�P'Y, That> ndividual Sewage Disposal System constructed ( ) or Repaired ( )
---Inshlln
SYSTEM WILL �INsTIC}N SAJjs€AfiTORY.
DATE ( i+ Cl/ �y L/CJ Inspector
No L.D..."."..L.Cd
THE COMMONWEALTH OF MASSACHUSETTS
BOARD OF HEALTH
Disposal nrl flipnotr inn ¥rrmit
Permission is hereby granted r? Ql �h _,^..'
to Construct ( ) or RepaS_ ) an Individual Sewage Dispostal 35ystem
at No /./..1{.. - g6_..f�,si..4..y.. ..:..-�........_. 7i s�
as shown on the application for Disposal Works Construction Perni Ng^ ' .E. Datted?2/L.r/2
DATE �; -9_' L.) .76
255 A. M. SULH(N/.e INC.. BOSTON
FORM I23
(_.%Board of Health
CHECK OR FILL IN WHERE APPLICABLE
ANTHONY
GRACIA
No.29701
FOISTI
THE COMMONWEALTH OF MASSACHUSETTS
_47--��BIOARD �O/F HEALTH
OF
nit fur Biiipnztti rc orb Cnnnntrurtian hermit
Application is hereby made for a Permit to Construct ( ) or Repai
System at:
an Individual Sewage Disposal
S—c f..L_Y.te. LoD;Pa`(I..e(V `J-,`,' L.- or Lot Na
Cl Address
1i/staffer Address
Type of Building Size Lot. Sq. feet
Dwelling—No. of Bedrooms s.Jr Expansion Attic ( ) Garbage Grinder ( )
Other—Type of Building No. of persons Showers ( ) — Cafeteria ( )
Other fixtures
Design Flow .T,r gallons per person per Oay. Total daily flow iir r0 gallons.
Septic Tank—Liquid capacje6a0 gallons Irength / • Width...r Diameter Depth¢
Disposal Trench—No. '��f{{ Width..lt2 Total Length.a2 .�...LtTotal leaching area /110 sq. ft.
Seepage Pit No Diameter Depth below inlet Total leaching area sq. ft.
Other Distribution box X) Dosing tank ( ) p
Percolation Test Results Performed by.. 3'/9 ter,c:4-7, AS Date...Z.:V-2J
Test Pit No. I as minutes per inch Depth of Test Pit 9/ Depth to ground water —
Test Pit No. 2 minutes per inch Depth of Test Pit Depth to ground water
Description of Soil ,5./AVAP 9 1:4411 r
ea S edoeg/Pc7 i)
Nature of Repairs or Alterations—Answer when applicable
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 n issued by the r health.
Signed.
Application Approved By
Application Disapproved for the following reasons
Date
Date
Permit No Issued.
by
THE COMMONWEALTH OF MASSACHUSETTS
BOARD OF HEALTH
OF
QQrrtifiratr of ainmplianrr
THIS IS TO CERTIFY, That the Individual Sewage Disposal System constructed ( ) or Repaired ( )
Installer
at
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 dated_
THE ISSUANCE OF THIS CERTIFICATE SHALL NOT BE CONSTRUED AS A GUARANTEE THAT THE
SYSTEM WILL FUNCTION SATISFACTORY.
DATE Inspector
No
THE COMMONWEALTH OF MASSACHUSETTS
BOARD OF HEALTH
OF
Disposal
lili
nrhn ftnnstrurtinn 1rrmit
do
Fae..S7/e)
Permission is hereby granted
to Construct ( ) or Repair ( ) an Individual Sewage Disposal System
at No
Street
as shown on the application for Disposal Works Construction Permit No Dated
Board of Health
DATE
FORM 1255 A. M. SULKIN, BOSTON