Lot 5-A Title 5 Application/Permits 1970, 1968 CHECK OR FILL IN WHERE APPLICABLE
No..32..1._
THE COMMONWEALTH OF MASSACHUSETTS
BOARD 051 F HEALTH
OF
.Appluatinn fur Disposal L O�ii nr�ks?Qtnnsfrurfiun Permit
Fee
Application is hereby made for a Permit to Construct (17)-Or Repair ( ) an Individual Sewage Disposal
System at:
h.s,y er
-
or L
or rot No.
Address
Address
Type of Building Size Lot 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.
Septic Tank—Liquid capacity/O .Qgallons 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.f te....y5ry ft.n
Other Distribution box ( ) Dosing tank ( ) P"�TT��
Percolation Test Results Performed by Date V' . .0
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
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 Article XI 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�he/alth.(}�
Signedf_�..�..lP '.` .o`c(i U
1r-L.l�1 G
O
Application Approved By :?:t...% SeXnlijen-
Application Disapproved for the following reasons
Permit No._3.d...7 Issued
Date
by
at N'
THE COMMONWEALTH OF MASSACHUSETTS
BOARD OF HEALTH
OF
errtifiratr'of Odnutpliunrr
THIS LS TO CERTIFY, That the Individual Sewage Disposal System constructed (t <r Repaired
has been installed in accordance with the provisions of Article XI of The State Sanitary Code as described in the
application for Disposal Works Construction Permit No 4.. dated -- , 1'2 6
THE ISSUANCE OF THIS CERTIFICATE SHALL NOT BE CONSTRUED AS A GUARANTE&THAT THE
SYSTEM WILL FUNCTION SATISFACTORY.
•
DATE ..a .�,, !'
Tyt. Inspector..:.,....
� b
THE COMMONWEALTH OF MASSACHUSETTS
BOARD OF HEALTH
{ e.,
p �>
'LL Fee OF - - 7t:-1i!.7 I-.
No.._
flispnsal rr;arks i2nnstrurtinn Vrrmit
Permission ss eby granted C4._...t_i.1 ai.c.=.e..0 e
to Construct ( or Repair ( ) an Individual Sewage Disposal Stem
at No Z.... :...!4- R.:.4 `„rt.L....c.r a;�::_
Sheet
as shown on the application for Disposal Works Construction Permit No.. .[:-{ Dated....:Ekf::=.._.a'L% / 27 '
/
i of HeaaL
DATE
FORM 1255 50555 & WARREN. INC.. PUBLISHERS
'HERE APPLICABLE
CHECK OR FILL IN
No
THE COMMONWEALTH OF MASSACHUSETTS
FEE
�/ BOARD F HEALTH
LTH
04I _ OF engs —�Trt Tvk)
Application fur Disposal Bonds (nnnstrnriinn Wrath
Application is hereby made for a Permit to Construct ( or Repair ( ) an Indir idual Sewage Disposal
System at:
M1..H-f'l.c.A l t - [ f ,579
)j L t No
A - 426- .SD
Owner Address
Installer
Type of Building
Dwelling-- No. of Bedrooms Expansion Attic ( ) Garbage Grinder ( )
Other—Type of Building No. of persons Showers ( ) — Cafeteria ( )
Other fixtures
Design Flow _2-. gallons per person per day. Total daily flow Ad d gallons.
Septic "tank—Liquid capacityf/!bd gallons Length Width Diameter Depth
Disposal Trench—No Width Total Length Total leaching area sq. ft.
Seepage Pit No Diameter D . h below inle Total leaching area sq. ft.
Other Distribution box ( ) Dosing -
Percolation Test Results Performed by .. ....tt . _ Date....2i.p.CL_
Test Pit No. I._5 minutes per inch Depth of Test Pit. D: to ground waterer ...i;_
Test Pit No. 2 minutes per inch Depth of Test Pit Depth to ground water
Address
Size Lot Sq. feet
Description o Soil (y1,- -_. ''er''' � �
lr 3...
)t -.n - &S'
Nature of Repairs or Alterations—Answer when applicable
Agreement:
The undersigned agrees to install the aforedescribed Individual Sewage Disposal System in
the provisions of Article XI of the State Sanitary Code—The undersigned further agrees not to pl e sysjent"`iti}'.
operation until a Certificate of Compliance has been issued by the board of health. �IYf'/'�,s <i,
Signed .7"ltP'. K,I
Application Approved By
Application Disapproved for the following reasons
Permit No
Issued
Date