Misc. Septic Application 6 CHECK OR FILL IN WHERE APPLICABLE
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THE COMMONWEALTH OF MASSACHUSETTS
BOARD OF HEALTH
��Lii.... OF ��p'K'HQ'M.}"��I.
Application far fflispuEaI iflurlt�(Ean5trnrtiau Vaunt
Application is hereby made for a Permit to Construct
System at: /r6-8 /, nd0
Oxn
Type of Building
Dwelling—No. of Bedrooms Expansion Attic ( ) Garbage Grinder ( )
Other—Type of Building .. No. of {car m Showers ( ) — Cafeteria ( )
Other fixtures
Design Flow _ gallons per person per day. Total daily flow gallons.
Septic Tank—Liquid capacity( —r° egnllons Length Width_ _ Diameter Depth
Disposal Trench—No. Width- ) Total Length D Total leaching area-j a A, ' sq. ft
Seepage Pit No Diameter Depth below inlet Total lead area sq. it
Dosing tank ( )
Performed by - Date
minutes per inch Depth of Test Pit Depth to ground wate- -
minutes per inch Depth of Test Pit Depth to ground water
or Repair ( ) an Individual Sewage Disposal
or Lot Na.
Address
Address
Size Jot Sq. feet
Other Distribution box
Percolation Test Results
Test Fit No. 1
Test Pit No. 2
Description of Soil
Nature of Repairs or Alterations—Answer when applicable
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 undersigned further agrees not to place the system in
operation until a Certificate of Compliance has bin i'sued by thelsboard of he-lth.
Application Approved By
.. x? (1-4"1 %GL- ...i tl TY
Application Disapproved for the following reasons'
Permit No (I'- 5
Dane
Issued._.JLfL'. �_./l..GG 15'
Date
by
THE COMMONWEALTH OF MASSACHUSETTS
BOARD OF HEALTH
OF
Trrtiftratr of Tampliancr
THIS IS TO CERTIFY, That the Individual Sewage Disposal System constructed ( ) or Repaired
)
mstauer
at
has been installed in accordance with the provisions of Article X1 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.
DATE
Inspector