Misc. Septic Application 5 CHECK OR FILL IN
No 70-- F'uu c.i., er 0
THE COMMONWEALTH OF MASSACHUSETTS
BOARD OF HEALTH
Cat OF )1C-gita
P ppliratinit fur D14 116111 itinrk,i Cnnurtrurtinii Permit
Application is hereby made for a Permit to Construct (✓) or Repair (
System at: // --77)�----
Lkat oti
) an htdi.ideal Sewage disposal
or tot Not
g4ke QLL--L-lfi
Installer
Type of Building Size Lot Sq. feet
Dwelling—Ao. of Bedrooms Expansion Attic ( ) Garbage Grinder ( )
Other—Type of Building - No. of person; Showers ( ) --- Cafeteria ( )
Other fixtures
Design Flow gallons per person per day. Total daily flow gallons.
Septic funk—Liquid cal aritr gallons Length VA'idtlt Diameter_._._. ___ Dept'•
Disposal Trench-- No. Width Total Length Total !caching area
Seepage Pit No Diameter Depth bel ow inlet Total leaching are
) Dosing tank ( )
Performed by _ Date
minutes per inch Depth of Test Pit. Depth to ground watc-
minutes per inch Depth of Test Pit Depth to ground water
Address
Other Distribution box (
Percolation Test Results
Test Pit No. 1
Test Pit No. 2
sq. IL
sq. It
Description of Soil
Nature of Repairs or Alterations—Answer when applicable
Agreement:
The undersigned agrees to install the aforedescribed Individual Sew
the provisions of Article NI of the State Sanitary Code—flue undersigned
operation until a Certificate of Compliance has been issupfl by the board o %
c Disposal System in accordance with
rther agrees not to place the system in
Ith.
Signet
Application Approved By � _ ..-.4�...1.-f- -O" -f-tr- err?
Application Disapproved for the following reasons' U
-31,tf7k
Date
Date
Permit No 7-L'-t_
qq,� Date
Issued Li?Ccri ?%...jq7
by
THE COMMONWEALTH OF MASSACHUSETTS
BOARD OF HEALTH
OF
Qtrrtifiratr of Tamplianrr
THIS IS TO CERTIFY, That the Individual Sewage Disposal System constructed ( 1 or Repaired ( )
at
has been installed in accordance with the provisions of Article Ni of The State Sanitary Code as described in the
application for Disposal Works Con traction Permit No dated
THE ISSUANCE OF THIS CERTIFICATE SHALL NOT BE CONSTRUED AS A GUARANTEE THAT THE
SYSTEM WILL FUNCTION SATISFACTORY.
DATE Inspector
THE COMMONWEALTH OF MASSACHUSETTS
BOARD OF HEALTH
7/ OF 6!% {LUG117} _. FEE.42r .e
fli,pna orlt5 Trott traction lrrmit
Permission ereby granted . .(r.)4+71
to Construct ( ) r I ai ( ] ap.,[n ,idual ew,arse llispQyp 1 liys�em
at No t 4 Y1G.4'Cr
Str«,
as shown on the application for Disposal Works Construction P No._76.61.- Dated
DATE
FORM 1255 Hoses & WARREN. INC. PUBLISHERS
far,.34 /17A