251 Appliaction & Permit 1970 THE COMMONWEALTH OF MASSACHUSETTS
BOARD OF HEALTH
Fax
Application for Disposal narks arks iliunstrurtiun 1rrntit
Application is hereby made for a Permit to Construct ( ) or Repair (`) an Indic idual Sewage Disposal
System at:
Lom[i Addaas or Lot No.
Address
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 ,,tt gallons per person per day. Total daily flow gallons.
Septic "Tank—Liquid capacityPt gallons Length Width Diameter Depth
Disposal Trench--No. Width Total Length Total leaching area sq. ft.
Seepage Pit No Diameter Depth below inlet Total leaching area p sq. ft.
Other Distribution box ( ) Dosing tank ( ) ,Q- 7S ± _0€ILAl ia,
Percolation Test Results Performed by Date
Test Fit 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- 4mvL/. ..^..r.'?4—Atre�!� lilt
I±t)f4 ef2.., t...a e i4 —t(,re -R Js.A..eebc4_ Aul
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 to place the system in
operation until a Certificate of Compliance has been issued by the board of health. /J /� ,gyp
46444 Signed._(.,Lr11 id_a'-e- Ny `�- i/ rats l
a« ..97 CI
Application Disapproved for the following reasons
Application Approved By
Permit No 391 Issued-Z.
Date
1,....1.27..0.......
THE COMMONWEALTH OF MASSACHUSETTS
BOARD OF HEALTH
fitertiftratr of Otum ►'liana
THIS IS TO CERTIFY That the Individual Sewage Disposal System constructed ( ) or Repaired
by
.!J T` ! Installer
at ?4d` / �Yr...:,y,.._..Y.2t ...,ie!•
has been installed in accordance with the provisions of Article XI of The State Sanitary Cgde ap described in the
application for Disposal Works Construction Permit No ..j'.1 dated...-4,y},f._._l_jc.7„
THE ISSUANCE OF THIS CERTIFICATE SHALL NOT BE CONSTRUED AS A GUARANTEE THAT THE
SYSTEM WALL FUNCTION SATISFACTORY.
DATE a:,..,ca 1 t a It /e Inspector.. k=s. y `t t2a..gsS>`R
THE COMMONWEALTH OF MASSACHUSETTS
BOARD OF HEALTH
.}. OF l .r' t_- -..fa;t..
V
!Disposal PI.arks Qnnstrurtinn Permit
Permission is hereby granted... .. y `-r-t
to Construct ( ) or Repair (tedf an Individual Sewage Disposal System
at No f. f :%.;� •t:....:.. .4
eet
as shown on the application for Disposal Works Construction Permit No
DATF
PORM 1258 Hoses & WARREN. INC.. PUBLISHERS
FEE
Dated
R.:..:y
RoaN of Health