1262 Application & Permit 1970 THE COMMONWEALTH OF MASSACHUSETTS
BOARD OF HEALTH
� OF
Applirutidit far i7' iapuaul Marks Uiuttatrttrtiutt prratit
Application is hereby made for a Permit to Construct (X) or Repair ( ) an Individual Sewage Disposal
stem at: ) / ,�7 /'
Y, YA 1.. `°�- ft Lot No.
FEE
Address
Address
t„r,,,pet
Sq.
feet
Size Lot
ype of Budding Expansion Attic ( ) Garbage Grinder ( )
Dwelling—No. of Bedrooms_...5, E Showers ( ) __ Cafeteria ( )
Other—Type of Building
No. of persons
Other fixtures •gallons.
)esign Flow gallons per person per day. Total daily flow Depth
gallons Length Width Diameter P
)ispb l Trench nc Liquid capacity Width Total Length Total leaching area sq. ft.
Seepage p I it No -No. Depth below inlet Total leaching area sq. ft.
seage Pit No Diameter P
Jther Distribution box ( ) Dos ank ) (� 9- 1/ '70 c
.lFal dsa- '^.,_gme: Date
Percolation Test Results minutes per inch Depth of T {l 3 1 Depth to ground water .a-w.e..�s+-7
Test Pit No. I minutes per inch Depth of Tes it Depth to ground water
Test Pit No. � minutes per inch Depth of Test Pit Depth ground
C�c 4l
Description of Soil.._.d14-.u:A--,-!>ua�”-.+- e
Nature of Repairs or Alterations—Answer when applicable
Agreement:
The undersigned agrees to install the aforedescribed Individual Sewage Disposal System in accordance with
the provisions of Article %l 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 hoard of health
Signed
Application Approved By
Application Disapproved for the following reasons'
Date
Date
Date
Permit No
Issued mm
THE COMMONWEALTH OF MASSACHUSETTS
BOARD OF HEALTH
•
OF
Trrtifirttte of @Inncplittnrr
THIS IS TO CERTIFY, That the Individual Sewage Disposal System constructed ( ) or Repaired
by ',,.tract
at
has been installed in accordance with the provisions of Article XI of The State Sanitary Code as described in
application for Disposal Works Construction Permit No _
THE ISSUANCE OF THIS CERTIFICATE SHALL NOT BE CONSTRUED AS A GUARANTEE THAT
SYSTEM WILL FUNCTION SATKOeCTO^Y.
DATE Inspector
THE COMMONWEALTH OF MASSACHUSETTS
BOARD OF HEALTH •
OF FEE
No fliuponttl Turk¢ Lau ntrurtinn Urrutit
Permission is hereby granted
•
to Construct ( ) or Repair ( ) an Individual Sewage Disposal System
at No . .. .- SINN
as shown on the application for Disposal Works Construction Permit No
Dated
• Boo.d of xoanh
DATE
FORM 1255 HOBBS & WARREN. INC., PUBLISHERS — —_