88 Application & Permit 1993 L t) Sed. pi,. z.��n.. -
30
THE COMMONWEALTH OF MASSACHUSETTS
BOARD OF HEALTH
I v OF
NcRTri te.2Jtest
Appliratinn fur illispusul Works Cnnnstrnrtiun e
Application is hereby made for a Permit to Construct (✓) or Repair ( ) an Individual
at:
S-e-t_✓<S 7Th S,0/3.b
_ Location-Address or Lot No,
0MOrK}en^tL // ..13E1K.F-iz /Rug.r�e)f S,,;W��pipRI \,a,,,�' t g�
C1Ci.. 90 lid 44l II, &Ilea t� T Address Instal er 1 /C 6 1)(C. r r, f�� 4
Type of Building Size Lot v
Dwelling—No. of Bedrooms Expansion Attic ( ) Garbage Grinder (A/O)
Other—Type of Building No. of persons Showers ( ) — Cafeteria ( )
Other fixtures ti O gallons.
Design Flow .-r gallons per person per day. Total daily flow
Septic Tank—Liquid capacity_ 5c )gallons Length t " :1 Width_ _6)- Diameter Depth_5 ,_y..
Disposal Trench—No. 3..----- Width -0 Total Length /36 Total leaching area_ ...7 2-6 sq. ft.
Seepage Pit No Diameter Depth below inlet Total leaching area sq. ft.
Other Distribution box (') Dosing tank ( , )
Percolation Test Results Performed by �4CL i, 4S5O(--;5y.C5 Date n��/t" `3i I �� y
Test Pit No. 4 6 Z minutes per inch Depth of Test Pit /66) Depth to ground water 7 Z
Test Pit No. 2 1 ' minutes per inch Depth of Test Pit //4-.. Depth to ground water PSI'
Description of Soil PcE, s/5.7 E,47 SGPAe- 5Y1 Tr.r Pe,}rI FoZ 7aSi Jxir .S etc,
0 gS/PPnvS .
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 Environmental 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 /� /)
Application Approved By 1- /s
Application Disapproved for the following reasons: &w rd/0 tom+_(!plc '
Permit No. _ _ Issued
nitt
THE COMMONWEALTH OF MASSACHUSETTS
BOARD OF HEA ;TH
OF _. . > 1p
Certificate of Compliait
ndivA al Sew e Disposal System constructed ( ) or Repaired tcerke
has been installed accordance with the provisions of TITLE The State nvironmental Code as c}escribed in
the application HE ISSUANCE for Disposal THIS Construction SHALL No
3D—I dated Ll ./ jr
THE ISSUANCE OF THIS CERTIFICATE SHALL NOT BE CONSTRUED AS A GUARAFFFEE THAT THE
SYSTEM WILL FFUffff�111CTT ON SATISFACTORY.
} ,°b&
DATE S.NI , ..1,5—, Inspector
THE COMMONWEALTH OF MASSACHUSETTS
BOARD OF HEALTH
'Uo
t L.,14 Lr 12 0+
arlm Qtnq{ trur'tt tt lrrmif
tv t, Ka.t4.L-...- -. .
OF
3iupuSat
iDG
Permission is hereby granted
to Construct rP Repair' (m an 1p
at No .yi u '
III:
Sewage Dis sal
t LA Syst � I t L
je.
L' J=am Date
as shown on the application for Disposal Works Construction Perr1---
oard of Health
�So ` ,149/5
Y Gt
FEE..L
DATE ct
FORM 1255
X95
HOBBS & WARREN. INC.. PUBLISHERS
t