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