412 Application & Permit 1964 No
THE COMMONWEALTH OF MASSACHUSETTS
BOARDcy OFntIEALTH
Application for ljiupuuut Marko Qlrm,wtrnrtiun 11rrmit
Application is hereby made for a Permit to Construct Q' ) or Repair ( ) an Individual Sewage Disposal
System at:
Locattp.AddnAst
4
nstnller
or Lot 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 t .gallons per person per day. Total daily flow gallons
Septic Tank—Liquid capacity_I0 U gallons Length Width Diameter Depth
Disposal Trench-No. Width 1.3 Total Length °`% Total leaching area 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
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 place the system in
operation until a Certificate of Compliance has fbeen rpeped by the hcalg�lu //// t
_ . Signed /i'Ly'4,�..,,, s'",w�q
Application Approved By
Application Disapproved for the following reasons
Pie
Date
Permit No !
Issued
--Date
Data
- I'is7
THE COMMONWEALTH OF MASSACHUSETTS
BOARD OF HEALTH
OF //Oltn,?owpfBX
rrtifiratr of Tontoiiotur
THIS IS TO.CERTIFY„That She Jndividual Sewage Disposal System constructed
Lti
L't't4LJ C ( ttiii
by
% 'C
at °L ite Fs.
has been installed in accordance with the provisions of Articl I of The State Sanitary Cpde as d scjribed in the
application for Disposal Works Construction Permit No dated r-y''d F F y
THE ISSUANCE OF THIS CERTIFICATE SHALL NOT BE CONSTRUED AS A GUARANTEE THAT THE
) or Repaired ( )
Instancy
SYSTEM W L UNCTION SATISFACTORY.
DATE eL i I / Inspecto
THE COMMONWEALTH OF MASSACHUSEf TS
BOARD qF HEALTH
OF /? <rvrC'� .-p^Lin
1 fi
FEE
Elispnnal Work, ¶ n tturtinn tirrinit
Pevnission�ercby granted
to Construct (I ) or Rep ir,( ),an ividtnnl Sewage Disposal System
at No .-. ,;i. . ..
Street / / 2 J ' /%, /
as shown on the application for Disposal Works Construction Permit(No S Dated JJL li-�j Jr
rrL q jj Mir..;�t.;yl
BALM of Health
DATE
FORM 1255 HOBBS & WARREN. INC.. PUBLISHERS