24 Application & Permit 1976 THE COMMONWEALTH OF MASSACHUSETTS
,FSOARD OF HEALTH
Cti .> of l sirtet ,[
Appliration -fur Oi:ipn al Iilurkdt oeenuutrurtiatt piPriuit
Application is hereby made for a Permit to Construct ( ) or Repair (( n Individual Sewage Disposal
Iystem at:
ace-c-44-
pe of Building Size Lot Sq. feet
Dwelling—No. of Bedrooms Expansion Attic ( ) Garbage Grinder ( )
Other—Type of Building No of perauns Sho■ven ( ) Cafeteria ( )
Other nsutres .. .
design Flow gallons per person per day. Total daily flow gallon-
i(--slic fank Liquid capacity g:dlons Leng*h Width Dupil
)isposal Trench—No. AA Idth Total l.ength Total leaching, ar _ -- q fi.
ieepage I'it No Diameter Depth bcl ow inlet Total Ieacl:ing err'-. _ ap ft
)fher Distribution box ( ) Dosing tank ( )
'ercolation Test Results Performed by _ _ _ Date
Test Pit No. I minutes per inch Depth of list Pil Depth to ground watrr.
Test pit No. 2 minutes per inch Depth of 1 est Pit Depth to ground watt,-
.
of Lot No.
Description of Soil -
<:nure of Repairs or Alteenions—Answer when applicable
lgrccment:
The undersigned agrees to install the aforedesc ribed Individual Sewage Disposal System in c nre wit]:
he provisions of Article Al of the State Sanitary Code—The u16,N-signed further agrees not to ystem in
rperation until a Certificate of Compliance as been issued by the board of h -rle. th.
Signed hw�d
kpplication Approved By
4pplianion Disapproved for the following reasons'
Permit No
Issued
by
THE COMMONWEALTH OF MASSACHUSETTS
BOARD OF HEALTH
OF
1trrtifirate of Tomplianrr
THIS IS TO CERTIFY, That the Individual Sewage Disposal System constructed ( ) or Repaired ( )
ia:macr
at
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 dated
THE ISSUANCE OF THIS CERTIFICATE SHALL NOT BE CONSTRUED AS A GUARANTEE THAT THE
SYSTEM WILL FUNCTION SATISFACTORY.
DATF Inspector
No...
THE COMMONWEALTH OF MASSACHUSETTS
BOARD OF HEALTH
`( a c r
flhipomal illorko (tionotrurtion Permit
Permission is hereby gr nted(' y p - >i' p -�-«.
to Construct ( ) or.Rep3r - ) an I54iv ual Sewage Disposal System
at No a.-/.�/..... / / /
s - 7
as shown on the application for Disposal Works Construction Permit' No/ Dated .., ! 1 L7--J%y'
FEE) (l
DATF
FORM 1255 HOBBS & WARREN. INC-. PUBLISHERS