625 Application & Permit 1987 No
THE COMMONWEALTH OF MASSACHUSETTS
BOARD OF HEALTH
Tt OFNORTHAMPirTh ... _ . .
Fax 1 r .e.–OSL
)pplitutiun fur fliupuuttl iflurks Tunutruttiun lrrmit
Application is hereby made for a Permit to Construct ( ) or Repair (L/C an Individual Sewage Disposal
System at:
Type of Building
Dwelling— No. of Bedrooms
Other—Type of Building
Other fixtures
Design Flow
Septic Tank—Liquid capacity
-Disposal Trench No.
Seepage Pit No
Other Distribution box
Percolation Test Results
Test Pit No. I minutes per inch
Test Pit No. 2 minutes per inch
or Lot No.
Address
Expansion A
Address
Size Lot Sq. feet
c ( ) Garbage Grinder ( )
No. of persons Showers ( ) — Cafeteria ( )
gallons per person per day. Total daily flow gallons.
ca gallons Length Width Diameter Depth
Width 'fatal Length Total leaching area sq. ft.
Diameter Depth below inlet Total leaching area sq. ft.
Dosing tank ( )
Performed by Date
Depth of Test Pit Depth to ground water
Depth of Test Pit Depth to ground water
Description of Soil
Nature of Repairs or Alterat
_trap
Agreement:
The undersigned agrees
the provisions of TITLE 5 of
operation until a Certificate of
Application Approved By
Application Disapproved for the following reasons'
ns— swer w en a Ipp icable
o install the aforedescribed Individual Sewage Disposal System
the State Sanitary Code—The undersigned further agrees not to
Compliance)as been is ed by the oard of he
in accordance with
place the system in
Permit No
Issued_
Date
Date
THE COMMONWEALTH OF MASSACHUSETTS
BOARD OF HEALTH
7 oF, Nljc;,7 HR IV T'
Oirrtifiratr of Qlompliattrr
THIS I O TIFY, h i• e IndividuaLSewage Disposal System constructed ( ) or Repaired (/�
by !g, a
II��,+11 - { m.mner
at (pas IsSLT�'"_/'s f (r
has been installed in accordance with the provisions a TIT I Sep he State Sanitary Cod desc to the
application for Disposal Works Construction Permit No o / dated r. ..d
THE ISSUANCE OF THIS CERTIFICATE SHALL NOT BE CONST ED S A GU;. N T THE
SYSTEM WILL FUMCTION SATISFACTORY.
DATE
No
-Dsdi /2
Inspector
THE COMMONWEALTH OF MASSACHUSETTS
BOARD OF HEALTH
OFS . . _ .. . . . . .....
Disposal
cr;
orbs «Cpnsirurtion tirrmit
Permission is hereby granted
to Construct ( ),or,Repair ( '') at IndividtTl Sewage Disposal System
at No
Nye
Street - . .
as shown on the application for Disposal Works Construction Permit No Dated
Board of Health
DATE
FORM 1255 A. M. St1LKIN, INC., BOSTON