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