669 Application & Permit 1976 THE COMMONWEALTH OF MASSACHUSETTS
BOARD OF HEALTH
OF
Fes$'
1ppliratinn -fur"fli5pnnni nrkn (4ntt5trur�timt Permit
Application is hereby made for a Permit to Construct ( ) or Repair (
System at:
1
.ocat.oa-Add
'tf t:1.1,
n Individual Sewage Disposal
or Lot No.
Address
s Addres,
a
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 gallons per person per day. Total daily flow
Septic Tank—Liquid capacity 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
Other Distribution box ( ) Dosing tank ( )
Date
Percolation Test Results Performed by Depth to ground water_
'lest Pit No. 1 minutes per inch Depth of Test Pit p g
to Depth ground water
Test Pit No. 2 minutes per inch Depth of Test Pit De 1 g
gallon,.
Description of Soil
1 c. Yttif. -47-
Nature of Repairs or Nteranons—Answerwhen ap liel le J - u`?✓5-
.UG.e.1_ ._ ll
Agreement:
The undersigned agrees to install the aforcdescrihed 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.
Signed
i1, +7a7c2 ;AI
Application Approved By 14 Date
V
Application Disapproved for the following reasons-
Permit No
Date
Issued CeeaL te-f.X
(1 Date
by
THE COMMONWEALTH OF MASSACHUSETTS
BOARD OF HEALTH
OF _
QIertifirate of fltnmplianrr
THIS IS TO CERTIFY, That the Individual Sewage Disposal System constructed ( 1 or Repaired (
IERRIcr
at
has been installed in accordance with the provisions of article XI of The State Sanitary Code as described in the
application for Disposal Works Construction Permit No dated
THE ISSUANCE OF THIS CERTIFICATE SHALL NOT BE CONSTRUED AS A GUARANTEE THAT THE
SYSTEM WILL FUNCTION SATISFACTORY.
DATE Inspector
THE COMMONWEALTH OF MASSACHUSETTS
BOARD OF HEALTH
OF /0 M, f
�i,pn�tt�tflinrks Tpnatrnrtinn liirrmit
Permission is hereby granted t.-f_�LSte.¢(...J,_T-k ritet+-�-L-
to Construct�( ) or Repair (✓ Individual Sewage Disposal System at No
FE
as shown on the application for Disposal Works Construction Per it No..4�.4 � /_L,(��'G/c9. /y/e'
Uated. �,
DATE
FORM 1255 Hoses & WARREN, INC_ PUBLISHERS