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587 Application & Permit 1978 I Li THE COMMONWEALTH OF MASSACHUSETTS Fng `5 0 6 7 BOARD HEALTH OF CIAO Oispnnat Wurka Cuntitrurlinn 1)ermit � Application is hereby made for a Permit to Construct ( ) or Repair ( ) :,: i .adiv ideal Setvagc `sposu "stem at: \ tee_c � �A A Installer (/ feet ype of Building Size Lot Sq.q Dwelling—Vo. of Bedrooms- Expansion Attic ( ) Garbage Grinder ( ) Other—Type of Building No- of InrInuus Sliesvelsn ( ) — Cafeteria ( ) Otter hstures .gallon) esign Flow gallons per p Ison per cat Total d t c [c Tank—Liquid capacity gallons Length VV dell- _- Di:unet r Dept po s tl Trench—No. AAidth _ Total Length Total leaching aren_. 'Fl t. e th below inlet Total leaching area II ezpage Pit No Diameter ll D P Ither Distribution box ( ) Dosing tank ( ) Percolation Test Results Performed by Date minutes per inch Depth of Test Pit- Depth to gromul water Test Pit No. 1 per Depth to ground wall^' - Test Pit No. 2 minutes per inch Depth of Test Pit p gro )ascription of Soil C1 � vamre of Repairs or Alterations—Answer when applicable- - - (I Agreement: The undersigned agrees to install the aforedescrihed Individual Sewage Disposal System in accordance with he provisions of Article Ni of the State Sanitary Code—The undersigned further agrees not to place the system in )peration until a Certificate of Compliance has been ' sued by he board of health. Signed -.-- 1/1/12-14/94-4/n1-{�j-°�'1 Application Approved By ''�I � -` tr V• Application Disapproved for the foil ng reaso jt.L5_I 197 ' /VI Me Permit No._{yI f y THE COMMONWEALTH OF MASSACHUSETTS BOARD OF HEALTH OF Qtrrtifiratr of fdumplianrr THIS IS TO CERTIFY, That the Individual Sewage Disposal System constructed ( ) or Repaired ttettanrt is been installed in accordance with the provisions of Article XI of The State Sanitary Code as described in the pplication for Disposal Works Construction Permit No dated THE ISSUANCE OF THIS CERTIFICATE SHALL NOT BE CONSTRUED AS A GUARANTEE THAT THE IYSTEM WILL FUNCTION SATISFACTORY. /ATE Inspector Io THE COMMONWEALTH OF MASSACHUSETTS BOARD OF HEALTH OF Elt5panal_Illorka Cnunnirurtion tirrmit Permission is hereby granted o Construct ( ) or Repair ( "f, an Individual Sew9.lge Disposal ‹ystem t No _ Street s shown on the application for Disposal Works Construction Permit.No Dated FEE Board of Health )ATE ORM 1255 HORSE & WARREN. INC.. PUBLISHERS