763 Application & Permit 1982 THE COMMONWEALTH OF MASSACHUSETTS
CA
BOARD OF HE LTH
t .t.t,(� OF
1ppiira#inn fur 3lispusal Mirka Truntrurtinu tinntit
Application is hereby made for a Permit to Construct ( ) or Repair ( an Individual Sewage Disposal
Address
Address
pe 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
sign Flow gallons per person per day. Total daily flow gallons.
ptic Tank—Liquid capacity gallons Length Width
aposal Trench—No. Width
epage Pit No Diameter Depth below inlet
her Distribution box ( ) Dosing tank ( )
rcolation Test Results Performed by .._ _ . . . Date
Test l'it 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
Diameter Depth
Total Length Total leaching area sq. ft.
Total leaching area /ire
ascription of Soil
ature of
;rcen nt:
The undersigned agrees to install the aforedescribed Individual Sewage Disposal System
e provisions of:IT i. 5 of the State Sanitary Code— The undersigned further agrees not to
aeration until a Certificate of Compliance has been issued by the board of health.
Signe —It\f
or Alterations j{—A ver when applicable
i
t i
pplication Approved By
in accordance with
place the system in
//
}_
Date
pplication Disapproved for the folioa'ing reasons'
Date
Permit No
8a--- Issued 441—
y
THIS
THE COMMONWEALTH OF MASSACHUSETTS
BOARD OF HEALTH
OF
Trriifiratr of Tumptiatta
IS TOSE RTIFY, T1t4Sid:.vidual cSfeyvhig74Dis Syst m chSu ed (
76
a...ei:Repaired (X)
eggscribed in the
Is been installed in accordance with t le provisions of TiiTES 5 of The State Sanitary Code
dated //
pplication for Disposal Works Construction Permit No
THE ISSUANCE OF THIS CERTIFICATE SHALL NOT BE CONSTRUED AS A GUARANTEE THAT THE
■YSTEM WILL FUNCTI N SATISFACTORY.
)ATE
o
Inspector
THE COMMONWEALTH OF MASSACHUSETTS
BOARD OF HEALTH
OF
Disposal Itinritz lingtritrtiint iltrutit
Permission is hereby granted
) Construct ( ) or Repair (t an Individual Sewage Disposal System
t No
_
FEE
Street
s shown on the application for Disposal Works Construction Permit No
)ATE
JRM 1255 HOBBS & WARREN. INC.. PUBLISHERS
— Dated
s
Board of Health
—