560 Application & Permit 1998 THE COMMONWEALTH OF MASSACHUSETTS
BOARD OF HEALTH
.!S OF.NSQFdTNANIPI C. '
F
3pplirntinn fur Di5prnFt1 Ciunstrnrtiun Permit
Application is hereby made for a Permit )
or Repair ()c) an Individual Sewage Disposal
tem at:
to Construct
DC of Building
Dwelling— No. of Bedrooms
Other—Type of Building
Other fixtures
sign Flow ga
ptic Tank—Liquid capacity gal
sposal Trench--No. Wid
epage Pit No Diameter
:her Distribution box ( )
trcolation Test Results Performed
Test Pit No. 1 minutes per
Test Pit No. 2 minutes per
or Lot No.
Address
Address
Size Lot Sq. feet
Expansion Attic ( ) Garbage Grinder ( )
Showers ( ) — Cafeteria ( )
No. of persons
gallons.
lions per person per day.Width daily flow Depth
ons Length Width Diameter
th Total Length Total leaching area sq. ft.
Depth below inlet Total leaching area sq. ft.
Dosing tank ( ) Date
by Depth to ound water
inch Depth of Test Pit Depth to ground water
inch Depth of Test Pit P
escription of Soil
1 e of epa rs or Alterat onsa Answwe
1 51,0
The undersigned agrees to install the aforedescrihed Individual Sewage Disposal System in accordance with
r wwgetteapplf
\greetnent: (1
he provisions of TITLE 5 of the State Sanitary Code—The undersigned further agrees not to place the system in
>peration until a Certificate of Compliance has a issued the board of health. ��'
' / ry o .G
Application Approved By
Application Disapproved for the following reasons
Date
Permit No
Issued.
Date
THIS uuTO C
,JnS
THE COMMONWEALTH OF MASSACHUSETTS
BOARD OF HEALTH
OF NURihu1v��'i'
Qlrrtif raft of Qlumptiantn
TIT«Y, Th t the Individual Sewage Disposal System constructed
it �
�(:O 4CAM?- f
been installed in accordat(ce with the provisions of TITLE 5 of The State Sadintearry Code as described in the
dication for Disposal Works Construction Permit No
THE ISSUANCE OF THIS CERTIFICATE SHALL NOT BE CONSTRUED AS A GUARANTEE THAT THE
STEM WILL FUNCTION SATISFACTORY.
.TE Inspector
staler
or Repaired (A
a
THE COMMONWEALTH OF MASSACHUSETTS
BOARD OF HEALTH
�FN∎frt: I H.Ar.p p Y. 1■
flisxnsal melts Cticau truttimn Permit
Permission is hereby granted -./ Dis
Construct ( ) or Rwair ( K) anelndivldual,Sa f
No e.T�..,�..( '�'t..a':.. V a_
shown on the application for Disposal Works Construction Pe
L
1System
Fax
ATE
)RM 1255 P. M. SULKIN}INC.. BOSTON
St
r D,t4
Hwrd of Health