112 Septic Application 1976 CHECK OR FILL IN WHERE APPLICABLE
THE COMMONWEALTH OF MASSACHUSETTS
OARD F HEALTH
OF
.Application for iiinprnttl illorko nn,itrurttnn OOrrutit
FEE -3T..�!_a
Application is hereby made for a Permit to Construct
System at: r
Location-.1dd!
taiier
or Repair (kin Lodi t i<lual Sewage Disposal
Le: No.
Address
aite
Address
Type of Building Size Lot Sq. feet
Dwelling—No. of Bedrooms Expansion Attic ( ) Garbage Grinder ( )
Other—Type of Building .. No. of pc: uns Showers ( ) — Cafeteria ( )
Other fixtures
Design Flow gallons per person per day. Total daily flow gallon-
Septic ttutk—Liquid capacity gallons Length Width Diameter --- Depth
Disposal Trench--No. Width Total Length Total leaching area sq. ft-
Seepage Pit No Diameter Depth below inlet Total leaching area sq. it
Dosing tank ( )
Performed by Date
minutes per inch Depth of Test Pit Depth to ground water
nunutes per inch Depth of "Kest Pit Depth to ground water
Other Distribution box
Percolation Test Results
Test Pit No. 1
Test Pit No. 2
Description of Soil
Nature of Repairs or Altera
Agreement.
The undersigned agrees to install the aforedescribed Individual Sewage Disposal System in accordance with
the provisions of Article NI of the State Sanitary Code—The un ersigned further agrees not to place the system in
operation until a Certificate of Compliance has be n issued by the
A-t (- -�
Application Approved Dy /sL ��-t �(.l.us-C !na<' ��
o U e
Application Disapproved for the following reasons'
:ns—Answe when applicable_pc-C. . _bfl-tt /wig
,rlJt- e anac:rZec. to in . y lei A
ed
GgSsh
Permit No 7r_a
Issued
Dat
l L_974e
by
THIS IS TO CEP
THE COMMONWEALTH OF MASSACHUSETTS
BOARD OF HEALTH
OF
@irrtifiratr of fllnmpltaurr
IFY, That the Individual Sewage Disposal System constructed ( ) or Repaired ( )
Insaner
at
has been installed in accordance with the provisions of :Article XI of The State Sanitary Code as described in the
application for Disposal Works Construction Permit No dated
THE ISSUANCE OF THIS CERTIFICATE SHALL NOT BE CONSTRUED AS A GUARANTEE THAT THE
SYSTEM WILL FUNCTION SATISFACTORY.
D ATE Inspector