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11 Application & PErmit 1977 72.6 Fros-.57 0 e THE COMMONWEALTH OF MASSACHUSETTS BOARD OF HEALTH ! r ppliratinn OF nr flir]pm ttl Ulurlu' Application is hereby made for a Permit to Construct tem at: 211(efut— LC,4/S1 BeKtO/14 XL- Installor re of Building Dwelling—No. of Bedrooms Other—Type of Building Other nxtures ;ign Flow rtic TGnk—Liquid capacity _.gallons posal Trench—No Width :page Pit No Diameter untitri► or Repair lirrinit nditidnal Sewage Disposal or Lot Na Add Size Lot Sq. feet Expansion Attic ( ) Garbage Grinder ( ) Showers ( ) — Cafeteria ( ) No. ter Distribution box ( tolation Test Results Test Pit No. I Test Pit No. 2 per person per day. "Fetal daily :low r Ilon. Length Width Dian eter__ _. __ Deptl. Total Length Total leaching area Depth below inlet Total leaching arch si_ ft Dosing tank ( ) Performed by Date minutes per inch Depth of Test Pit Depth to ground water nMutes per inch Depth of Test Pit Depth to ground mater______.__. scription of Soil tare of P.epairs or N[eratinns—Answer when applicable _ _t,�-/mop reement: The undersigned agrees to install the aforedescrihed Individual Sewage Disposal System in accordance with provisions of Article XI of the State Sanitary Code— The undersigned further agrees not to place the system in ration until a Certificate of Compliance has byn is red by the U aarrd of 1}e�lth plication Approved Dy . - - -U �V�j{"�" -/777 11011 °�` 'plication Disapproved for the following reasons' THE COMMONWEALTH OF MASSACHUSETTS BOARD OF HEALTH 4rrfifirate of friortipliatur THIS IS TO CERTIEY,,That/,he Individual Sewage Disposal System constructed ( ) or Repaired it Installer been installed in accordance with the provisions of Article XI of The State Sanitary Code as described in the 'ligation for Disposal Works Construction Permit No 2 k 6 dated__.af'„ _��yL /_/,x..77 THE ISSUANCE OF THIS CERTIFICATE SHALL NOT BE CONSTRUED AS A GUARANTEE THAT THE STEM WILL FUNCTION SATISFACTORY. - -- i i 7 77 Ins ector :r a G ) 7 yet Ti' _ I—r�.J'. P li Permission Construct No ;Flown on the THE COMMONWEALTH OF MASSACHUSETTS BOARD OF HEALTH OF ,- - iJinpnsal Marks Qlnnntrurtinu Wroth is hereby granted ' �{,� g .fit Jyptytor or Repair ( /), an Individual Sewage Disposal System FEE Street application for Disposal Works Construction Permit No Dated .TE M 1255 HOBBS & WARREN, INC.. PUBLISHERS Board of n2olm