246 Application & Permit 1973 THE COMMONWEALTH OF MASSACHUSETTS
BOARD OF HEALTH
i OF Prtttti
Application for ttopooat Works �Dtta rrt io Prrl Sewage Disposal
Application is hereby made for a Permit to Construct (' ) or Repair ( ) an
'System at:
4.21 .k yya��i R m or Lot No.
V Addvess
O
SC
i q. 4e
anal Size I of -. --
m ° Garbage Grinder ( )
Type of Building _ Expansion Attic ( ) Cafeteria ( )
-- _ Showers ( )
Dwelling 1h o. of Bedrooms -- - No. of persons --
Other—Tthe of Building -- _. —". ...
gallon-
Design fixtures gallons per person per day Total daily flow.
Depth
- U unene it,/.0 Qsq ft
Length _. Width -
Ue+ign Flow - - - Ih n __Total leaching anti sq ft
Tank Liquid cap c t Width ____Total Length_
No . er-- h .__. Total leaching area--
Disposal Trench—L`° -- _ Depth below inlet --
1 it �o _. Diameter
Seepage Dosing tank ( Date
.._.. .. . - ate water
Percy Distribution n Test No. box performed by - Depth -,_. Depth to ground
Test Results -. Depth to ground water —
Test Pit No. L____ _minutes per inch Depth of Tot Pit— -- -.
__minutes per inch Depth of Test 'rt.-
Test Pit No. 2 __ ..
Description of Soil
-- ---- Answer when applicable _ ____ _ ___ ____ ___
.
Nature of Repairs or Alterations— - -
Agreement: further
the State Sanitary Code—The undersigned further agrees not to place the system in
The undersigned agrees to install the aforedescrrbed Individu l Sewage Disposal System in accordance with
the provisions t of Article I ...
r n,m
operation until a Certificate of Compliance has been issued by the ard health.
sd y1 [ 4TH.
. „Aryl __ - n i=
Application Disapproved df the following
__.
roved for the following reasons. Data
Application Disapp -- _
1lsn._ L 7 /yJ._. ._..
Issned
Date
_.___ Permit No_.. _i!.��_.__...__._._..____
THE COMMONWEALTH OF MASSACHUSETTS
BOARD OF HEALTH
rrtt itA
..... pt f to of finm` ltttnrr or Repaired ( )
l
T¢a.t the Individual Sewage Disposal System constructed
THISi,STOCE�TIF ..
Installer
by "-` }- ---- '- ode as described m the
1
am acv
� with the provisions of Article XI f The State dated
IRS h ///
application
SYSTEM WILL FUNCTION SATISFACTORY. Inspector_` ,
DATE THE COMMONWEALTH OF MASSACHUSETTS
BOARD OF HEALTH
been
at
installed in acwrda a wr
for Disposal Works THIS CERTIFICATE S SHALL THE ISSUANCE OF THIS CERTlFt ORY. SHALL NOT BE CONSTRUED AS A GUARANTEE THAT THE
FEE .va_.' .........
DiRpnattl,311nrkst Tnustrurttnu Prrutit _
em
Permission is —Re granted "" -'s _ --
o epav
an Individual Sewage slspo it Sy
as shown on u Dated it
to Construct
erne[ No
—�
application for Disposal Mocks Cons[rucnog
VP
rood
the a IIoa<Wd Health
DATE—............................. .... ............... ........ ................
FORM I ass HOBBS & WARREN_ INC. PUBLISHERS