47 Application & Permit 1982 10
No.e — ?1 FEE./e_ry
THE COMMONWEALTH OF MASSACHUSETTS
BOARD OFLTH
OF �
t
Appliratinn fur Elinpnsttl 'o arks Qtunstrurtinn hermit
Application is hereby made for a Permit to Construct ( ) or Repair ( Individual Sewage Disposal
System at: if? GIddw TAA
.......A at w " lai-t drss" (� rAt
a u, . Address
I oxtalle
Address
6 Type of Building Size Lot Sq. feet
Dwelling—No. of Bedrooms Expansion Attic ( ) Garbage Grinder ( )
WOther—Type of Building No. of persons Showers ( ) — Cafeteria ( )
a. Other fixtures
6
W Design Flow gallons per person per day. Total daily flow gallons.
W Septic Tank—Liquid capacity gallons Length Width Diameter Depth
2. Disposal Trench—No. Width Total Length Total leaching area sq. ft.
Seepage Pit No Diameter Depth below inlet Total leaching area_ sq. ft.
z Other Distribution box ( ) Dosing tank ( )
Percolation Test Results Performed by Date
jTest Pit No. I minutes per inch Depth of Test Pit Depth to ground water
W Test Pit No. 2 minutes per inch Depth of Test Pit Depth to ground water
c4
0 Description of Soil
g
W
U Nat re of Repai s or Alte ations—Answer when a icable ..
i
A eement:
The undersigned agrees to install the aforedescrihed Individual Sewage Disposal System in accordance with
the provisions of TITLE 5 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 .oard .f h h. //'
---k-Si • d .. 4 e.: ..... /. wi
OatgG
Application Approved By �fi` '/ _. , oAwD7
Application Disapproved for the following reaso - S
Date
Permit No c),..y] /7)— Issued rifaltD--
n
by
at '5/ 7 14J.%-4-
has been installed in accordance with the provisions of TITLE 5 of The State Sanitary Code a� esq bbed in the
application for Disposal Works Construction Permit No 1�..3 -g 1' dated F/01/8-
THE ISSUANCE OF THIS CERTIFICATE SHALL NOT BE CONSTRUED AS A GUARANTEE THAT THE
THE COMMONWEALTH OF MASSACHUSETTS
BOARD OF HEALTH
OF
tT
rrtifiratr 4 Qinmplianrr
THIS IS TO CERTIFY hattIt�y�tt��vtd�p�a� Sewage Disposal System constructed ( ) or Repaired (t3—
n/_e/1/L
SYSTEM WILL FUNCTION SATISFACTORY.
DATE ?rAls iPJ`
Inspector
THE COMMONWEALTH OF MASSACHUSETTS
BOARD OF HEALTH
OF f., rw
No a
Oispnsal i mho fount inn rrm
Permission is hereby granted
to Construct ( ) or Repair (1. an Indiv' u a Dt+ stem
at No 7U
Street
as shown on the application for Disposal Works Construction Permit N
DATE 17-.Y {g.'et.
FORM 1255 A. M. SULKIN, INC . BOSTON
don
FEE"C y`LI
/D$ted
, .,11 of of Health