Misc. Septic Application 12 THE ISSUANCE OF THIS CEROFtCAIt anN•.
SYSTEM WILL FUNCTION SATISFACTORY.
D ATE................................. .............................................
Inspector_.._._ _.._.._..._..__._._._-__... __._..._.......
•
CHECK OR FILL IN WHERE APPLICABLE
No
THE COMMONWEALTH OF MASSACHUSETTS
BOARD OF HEALTH
CitY OF -7orthnftptonz
FEE
Appliration for i3- iopomal Works Cnontitrurtiott lfrrntit
Application is hereby made for a Permit to Construct (X) or Repair ( ) an Individual Sewage Disposal
System at:
Chesterfield 3ord
Localon•Address or Lot No.
John Skibiski io,llag t.,--- a.);a:thzmpt.ca.,....'.4ass..
Address
Owner
Installer
Type of Building
Dwelling—No. of Bed rooms
Other—Type of Building Frame
Other fixtures
Design Flow
3
Address
Size Lot12S'X3001 Sq. feet
Expansion Atti9 ( ) Garbage Grinder ( )
No. of persons ,�la). O Showers ( ) — Cafeteria ( )
300 gallons.
50 gallons per person oer day. Total dal+ly flow
;ttj.000 .,lions I nnth 81 Width_ 4t
Septic Tank—Liquid can¢. g. Diameter
Disposal Trench-No. red Width 201 D Total Length 40t Total leaching area
Seepage Pit No
Other Distribution box ( X)
Percolation Test Results Perform
Test Pit No. L....ie.st minutes p
Test Pit No. 2—°"minutes p
Deea ho
Description of Soil 0" tQ 5" lo
sravel - no rust Dr.
Location test hole 1001 south of _'hestorfi.eld Rd Zr 5�t
Nature of-Repairs or .Alterations—Answer when applicable lot line.
Diameter
DDptl 5'
sq. ft.
Depth below inlet Total leaching area sq. ft.
Dosing nk /
ed by/ :... .:/".$444-401,4• S. Date S/3o 755
er inch Depth of Pest Pit 3 11t Depth to ground water None
Cr inc i Depth of Test Pit 120'! Depth to ground water -"Q.cs.
le :'orarr;;i - ....Lpaz3oa R"aaae_^.t,
an -�,Y"V to 1,8" 2Yrdx loraat - 43" to 1 "'0" clay &
east of west
Agreement:
The undersigned agrees to install the aforedescribed Individual Sewage Disposal System
the provisions of Article XI of the State Sanitary Code—The undersigned further agrees not to
operation until a Certificate of Compliancee+as been issued by the board of health.
'gnat
Application Approved By
Application Disapproved for the following reasons-
in accordance with
place the system in
513.0175
Date
Date
Permit No Issued
Date
by
THE COMMONWEALTH OF MASSACHUSETTS
BOARD OF HEALTH
Qlrrtifiratr of Clontplianrr
THIS IS TO CERTIFY, That the Individual Sewage'Disposal System constructed ( ) or Repaired
at
has been installed in accordance with the provisions of Article XI of The State Sanitary Code as described in the
aoufieation for Disposal Works Con>trucdo l Permit No dated
' .. .,nT or AS A GUARANTEE THAT THE
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John B.idzit, FMS.
19 Sumr:or S:rcer
Greenfield, iA.c s. 01301
5/30/70
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