33 Application & Permit 1967 THE COMMONWEALTH OF MASSACHUSETTS
BOARD OF HEALTH
OF
Fax
Application for fl;sposal rw orks Tonstrurtion jrrmit
Application is hereby made for a Permit to Construct ( ) or Repair (' ) an Individual Sewage Disposal
System at: !' L i/ i..-�.
Lotion-Address
-sn
Type of Building
Dwelling—No. of Bedrooms No. of persons
Other—Type of Building
Other fixtures
Design Flow gallons p
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
or Lot No.
Address
Address
Size Lot Sq. feet
Fxpansion Attic ( ) Garbage Grinder ( )
Showers ( ) — Cafeteria ( )
er 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 ( )
Description of Soil
Date
Depth to ground water
Depth to ground water
Nature of Repairs or Alterations—Answer when applicable
f/
cno-efz.%t
The undersigned agrees to install the aforedescribed Individual Sewage Disposal System in accordance with
Agreement:
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 health
Signed
/, Cua,/(en
Application Approved By
Application Disapproved for the following reasons-
ryI Date
ri .
Date
� ?? Issued.
Permit No set
Date
' 7x7
D
by
has been installed in accordance with the provisions of Article RI of The State Sanitary Code as described irythe
at
�Y l.k {
application for Disposal Works Construction Permit No �-s � dated - I�
THE ISSUANCE OF THIS CERTIFICATE SHALL NOT BE CONSTRUED AS A GUARANTEE THAT THE
SYSTEM WILL FUNCTION SATISFACTORY.
THE COMMONWEALTH OF MASSACHUSETTS
BOARD OF HEALTH
f OF /Pi-4:k.TW 4lH v
Qltrtifiratr of (QAntiliantr
THIS IS TO CERTIFY, That the Individual Sewage Disposal System constructed ( ) or Repaired (
Installer
No
Inspector
THE COMMONWEALTH OF MASSACHUSETTS
BOARD OF HEALTH
OF .. . ....... .
%panal rrnrks hianntrnrtinn Permit
FEE
Permission is hereby granted " "ty a
to Construct ( ) or Repair (I4 an Individual Sewage Dispbsal System
at No j-_1.'._,tanift-L L...ciiiectiwt
Street
as shown on the application for Disposal Works Construction Permit No Dated
Board qY Health
DATE
FORM 1255 HOBBS & WARREN. INC.. PUBLISHERS