462 Application & Permit 1983 v - ? 3
THE COMMONWEALTH OF MASSACHUSETTS
BOARD OF HEALTH
C/771 OF Y
. t'/!� /l�ia/!
FEE
/Q o/
Appliration for 3Ui5pli al 'irks Cnunutrurtiun hermit
Application is hereby made for a Permit to Construct ( ) or Repair ( ✓) an Individual Sewage Disposal
brZJ tia.,w..sAnv1 :.
em at:
Tan) /'49 M'2 4Y vveeNG
Ill
or Lot No.
Installer Address
e of Building Size Lot Sq. feel
Dwelling—No. of Bedrooms Expansion Attic ( ) Garbage Grinder ( )
Other—Type of Building
Other fixtures
ign Flow
tic Tank liquid capacity
iosal Trench--- No.
page Pit No Diameter Depth below inlet
er Distribution box ( ) Dosing tank ( )
colation Test Results Performed by Date
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 to ground water
No. of persons Showers ( ) — Cafeteria ( )
gallons per person per day. Total daily flow gallons.
gallons Length Width Diameter Depth
Width Total Length Total leaching area sq. ft.
Total leaching area sq. ft.
cription of Soil
Pure of Repairs or Alterations—Answer when applicable REP,48c _bM hee- 6DQ rGf,7cH F(Eine
tvagai New 6SO - 700 'LEnc/J F/w GA
reement:
The undersigned agrees to install the aforedescribed Individual Sewage Disposal System in accordance with
provisions of?1T12 5 of the State Sanitary Code—The undersigned further agrees not to place the system in
ration until a Certificate of Compliance has been issued by the board of health.
Signed
plication Approved By� �LLL/� !%
plication Disapproved for the following re¢sons
7/TFN .r
Date
Permit No f) -b' 3 Issued- 7. /k/73
Date
Date
THE COMMONWEALTH OF MASSACHUSETTS
BOARD OF HEALTH
sr/r/ OF_.ifiSt,-.?`r : .`:Y . ..
ffiertifutttt sf ( omplittnre
THIS IS TO CERTIFY, That the Individual Sewage Disposal System constructed ( ) or Repaired (V)
Installer
¥b- 42,4.0-c*',MMr✓Ah/•49A.D
been installed in accordance with the provisions of TITLE 5 of The State Sanitary Code a des9ribed in the
lication for Disposal Works Construction Permit No /1.4E4 dated 7 LP at
THE ISSUANCE OF THIS CERTIFICATE SHALL NOT BE CONSTRUED AS A GUA ANTEE T AT THE
STEM WILL FUNCTION SATISFACTORY. P�
TE /l.QAe3 Inspector
/t.
THE COMMONWEALTH OF MASSACHUSETTS
BOARD OF HEALTH
313is.pnsttl nrks Qinnstrurtisn 11rrmit
Permission is hereby granted rdit2)...fJia_ y..-g./dam
Construct ( ) or Repair (✓) an Individual Sewage Disposal System
No 461.2 Ln&c
FEE/
Street
shown on the application for Disposal Works Construction wicNo/ 3— c Dated - _/..E7 t
✓, ap _.
tTE
IM 1255 A. M. SULKIN, INC.. BOSTON