Misc. Septic Application 7 ERE APPLICABLE
No_k>3.7
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THE COMMONWEALTH OF MASSACHUSETTS
BOARD OF HEALTH
6' 1L OF
Appliration for 3iopoottl Itiorko oonitrnrtion I,Jrrmit
Application is hereby made for a Permit to Construct
System at:
XtT(r
hisnitat
lPkilt°:21r Address
or Repair (✓) an 1udi)idual Sewage Disposal
or cot No.
Installer Address
Type of Building Size Lot Sq. feet
Dwelling—No. of Bedrooms 3 Expanssion//kttic ( ) Garbage Grinder
Other— Type of Building No. of persons SO Showers ( ) — Cafeteria ( )
Other fixtures
Design now .3Q gallons per person per day Total daily flow 3_OQ__g:dlon-
Septic lank—Liquid capacitJ9 rallons LF.ngth \Vidth y Diameter._.. De tb
Disposal Trench—No. AA"idth.ari te0 d sq. ft.
Seepage Pit No Diameter Depth below inlet Total leaching area sl. fl
2 Other Distribution box ( V).-- Dosing tank ( )
Percolation Test Results Performed by Date
..1 Test Pit No. 1 minutes per inch Depth of Test I'it Depth to ground wate-
r-: Test Pit No. 2 minutes per inch Depth of Test Pit Depth to ground water
0 Description of Soil
w
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 be i ued by the board of health.
Si
Application Approved By % ( CZ4 7L
I L9Zy
Date
Application Disapproved for the following reasons'
Permit No 63 7 Issued.
pDate
1 _f.7-1r
by
THE COMMONWEALTH OF MASSACHUSETTS
BOARD OF HEALTH
OF
hlrrtifiratr of fllomplianrr
THIS IS TO CERTIFY, That the Individual Sewage Disposal System con
Instiller
ucted ( ) or Repaired
at
has been installed in accordance with the provisions of :Article X f 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