1062 Application & Permit 1972 THE COMMONWEALTH OF MASSACHUSETTS
ryB'OARD OF HEALTH
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p
Ltrij OF
Pppliration for Thupunt rH urks�Ciunstrurtion Vrrnnt
Application is hereby made for a Permit to Construct ( ) or Repair (' ) an Individual Sewage Disposal
TAM at
1.C..6 a n or Lot Na.
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FEE
leno-
Address
t"°`"'t°` Address
Size Lot Sq. feet
'ype of Building Garbage Grinder ( )
Dwelling Type of Bedrooms Expansion Attic ( )— No. of person Showers ( ) — Cafeteria ( )
Other—Type of Building P
Other fixtures gallons
)esign Flow gallons per person per day. Total daily flow g
gallons Length Width Diameter Depth
)ispol Tr nc Liquid capacity Total Length Total leaching area sq. ft.
;epage Pit No Width
)ther e Pit No
Diameter Depth below inlet Total leaching area sq. ft.
Rher Distribution box ( ) Dosing tank ( ) Date
Percolation Test Results Performed by Depth to e water
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 g
Description of Soil
Nature of Repairs or Alterations— Answer when applicable..
tote „el-id/AIL add,t,61zif
4 fro letdiL ,the 1;15 8.4
The undersigned agrees to install the aforedescribed Individual Sewage Disposal System in accordance with
Agreement:
the provisions of Article XI of the State Sanitary Code—The undersigned further agrees not to place the system in
operation until a Certificate of Compliance has been issued b the and of health.
(Q
Application Approved By
4{-€40' .t-E...,A. -
Application Disapproved for the following reasons
Permit No. Dace
Issued fa e / �
.�� f/
b
THE COMMONWEALTH OF MASSACHUSETTS
BOARD OF HEALTH
OF
@tertifirntr at Qtnntpttana
THIS IS TO CERTIFY, That the Individual Sewage Disposal System constructed ( ) or Repaired ( )
Installer
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.
DATE Inspector
THE COMMONWEALTH OF MASSACHUSETTS
BOARD OF HEALTH
Nom'_,(._; +"'6a+A,. it FEE.:: .04
Eitoposttl /I nrks (lmtsbriutintt rrmit
Permission is hereby granted.../<.,..:_c:.,.a.y :.:2:A {if t
to Construct ( ) or Repair (/) an/Individual Seeag Disposal gystem
at No G n-....-llF_.G.::.'-26i� t.. .#'
t.. +""� Y Street
as shown on the application for Disposal Works Construction Permit No...i..J-.) Dated
DATE
FORM 1255 140913S1 WARREN. INC.. PUBLISHERS
Board oT£Iealth