Off Henry St Applications & Permits •
No 5Y3
THE COMMONWEALTH OF MASSACHUSETTS
BOARD OF HEALTH
OF r �7
Application far aisponal Hotta Cnanstrurtinn Prrmit
FEE/,,:(..144
Application is hereby made for a Permit to Construct ({/) or Repair ( ) an Indie idual Sewage Disposal
System at:
1t/inis -u.. . 1it;i.
0
qp py., 0: Int 55o.
m
Ttid
Installer
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 J� /A� gallons per person per day. Total daily flow gallons.
Septic Tank-Liquid capacit}f i[ .gallons Length Width Diameter Depth
Disposal Trench—No. Width Total Length Total leaching area 62f../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. I 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 and srsigned further agrees not to place the system in
operation until a Certificate of Compliance has b n issued by the board of heal .
Signed. �� �-it -cif t �1lfttt�i .�
Application Approved By �E f"d
Application Disapproved for the following reason s• a ✓
Permit No...,.s4.3
Date
Issued "kV,n/2e ...L..47a.,�
THE COMMONWEALTH OF MASSACHUSETTS
BOARD OF HEALTH
OF ) -v.,
&rattail af &nuptial=
THWS TO URTIFY, Tha the Indivi,duaT Sewage pisposa,l,Sistem constructed (y1 or Repaired ( )
by Lii, c I ‘f v I
Installer I
at , t t s A: Z. I.. 4 f" ,t_
, -
has been installed in accordance with the provisions of Article XI k The State Sanitary Code as described in the
application for Disposal Works Construction Permit No fa. dated
THE ISSUANCE OF THIS CERTIFICATE SHALL NOT BE CONSTRUED AS A GUARANTEE T4IAT THE
SYSTEM WILL FUNCTION SATISFACTORY.
DATE
No -
„•
THE COMMONWEALTH OF MASSACHUSETTS
BOARD OF HEALTH
.44.4 OF
313thannal iI arks &instruction tiltttat
Permission is_hereby granted_ 'stab .2 t
to Construct (i; ) or Repair ) an Individual Sewage Disposal System
at No . 4-4,4
Street
as as shown on the application for Disposal Works Construction Permit No.—. Dated
DATE
FORM 1255 HOBBS & WARREN. INC., PUBLISHERS
Board of Health
No
Fez
THE COMMONWEALTH OF MASSACHUSETTS
BOARD OF HEALTH
67i/ OF . %K.7i%/CA417o.t/
A}polirtttian for Disposal i'i,urks Tonstrurtian permit
Application is hereby made for a Permit to Construct (✓S or Repair ( ) an Individual Sewage Disposal
System at:
A/
eey r7.
—^'--" inratiw��Addrem
Owner
Address
//a.f "$¢-feet
Installer Size Lot
Type ofBunging / Expansion.Attic (2) Garbage Grinder (�
Other—Type of Bedrooms — Cafeteria ( )
Other—Type of Building No. of persons......_........._.._..... Showers ( )
Other fixtures
gallons per person per day. Total daily flow 3°° _.._..._..........._�Mons
Design Flow y=G " Width d– G" Diameter Depth
Septic l T et Liquid capacity /•d< gallons 20 m�hTotal Length.._............_Total leaching area._eeQ.-...."sq. ft
Width 3c g
Disposal —No. Diameter Depth below inlet......._........_Total leaching area .............sq. ft.
Other Distribution No Dosing tank ( )
Percy a ioniT st box ( ) //_//_•uSF_C/.. t!Ar._.... Date..00.?.D:c. -"
Percolation Test .Results mutes er inch Depth ?tl Test p 3' f1A.(.... Depth to ground water..LO_-.p_'L.._.
re0 j Test Pit No. t { minutes per inch Depth of Test Pit eP '
"�o..gTest Pit No. 2p:--� minutes per inch Depth of Test Pila�A.€:.L4:. Depth to ground wattt.._L�_...9::._..
Description of Soil_et-7,9
.... F _7 " Ton !Cr =C 474- .7..�.• F/.
,JESAyQ:._;..._.t l.t...7
$ SYS ZE/27,n1 eeAir 7A 4t -.D /4' A2Ci4e ar= O/oc 1t-4 /3u LlN6 .........
Nature of Repairs or Alterations—Answer when applicable..............................................................................................
Agreement: Sewage System in accordance with
The undersigned agrees to install the aforedescribed Individual
n ividualgSed age Disposal
agrees not m to in place the system in
the provisions of Article XI of the State Sanitary Code—
operation until a Certificate of Compliance has been issued by the board of health
Signed
-
Date
Application Approved By
Application Disapproved for the following reasons:_........................................................_........._.................._..............
Date
Iasued........._..._._Date
or int N .
74 j/AaICEY J .Ty ?s..__...
Address
Date
Permit No