1472 Application & Pemmit 1970 ro 71
THE COMMONWEALTH OF MASSACHUSETTS
BOARD OF HEALTH
l.i
OF or-" r nom"" '
Fan
Application for "Inwood Hi arks Ulanatrnrtian Permit
r l�
Application Repair
is hereby made for a Permit to Construct ( ) epm ) an Individual Sewage Disposal
System at:
.0 7a »
a_, rea
or Lot No.
Address
Address
. . .. m,mner Size Lot Sq. feet
Type of Building Expansion Attic ( ) Garbage Grinder ( )
Oeri of Bedrooms No. of persons Showers ( ) — Cafeteria ( )
Othther——Type of Building
Other fixtures '" ' -" ' - gallons.
Design Flow gallons per person per day. Total daily flow
gallons Length Width Diameter Depth
Disposal Tank-Liquid capacity Width Total Length Total leaching area sq. ft.
Disposal Pit No—No. Total leaching area sq. ft.
Seepage Pit No Diameter Depth below inlet �
Other Distribution box ( ) Dosing tank ( ) Date
Percolation Test Results Performed by De th to round water
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 g
Description of Soil
Nature of Re
/�� _ _ _.
rs or Alterations—Answer when applicable-.,5�`e'°s-� -
The undersigned agrees to install the aforedescribed 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. l
Signed.._ 'ea.1'e_' 9J` —
Application Approved By
Application Disapproved for the following reasons'
Permit No._3.7.{
Issued.
if? 4
Dam
THE COMMONWEALTH OF MASSACHUSETTS
BOARD OF HEALTH
OF
airrtifitate of Toutpliatur
THIS IS TO CERTIFY, That the Individual Sewage Disposal System constructed ( ) or Repaired (- )
Installer
as been installed in accordance with the provisions of Article XI of The State Sanitary Code as described iii the
pplication for Disposal Works Construction Permit No dated
THE ISSUANCE OF THIS CERTIFICATE SHALL NOT BE CONSTRUED AS A GUARANTEE THAT THE
iYSTEM WILL FUNCTION SATISFACTORY.
)ATE 1 , ,
Inspector
Fo
THE COMMONWEALTH OF MASSACHUSETTS
BOARD OF HEALTH
OF
fliapunat Iri nrkn Clottotruction Frrittit
Permission is hereby granted
Construct ( ) or Repair ( an Individual Sewage Disposal System
No
FEE
Street
shown on the application for Disposal Works Construction Permit No Dated
kTE
7A1 1255 HOBBS & WARREN. INC.. PUBLISHERS
Board of Health