414 Septic Appication 1978 •■-■■•■■■■■•-•■■•■••■■••ThIrIMOIWIrrIrl•VN
CHECK OR PILL IN WHERE APPLICABLE
No i ce .
THE COMMONWEALTH OF MASSACHUSETTS
BOARD�O�OF HEALTH
OF CX7.?�-Lifdil27
Appliratian for fli,}TOOttl illurlui nu5trurtinu iJnmit
FEE .. 0 6
Application is hereby made for a Permit to Construct ( ) or Repair (I5 an light ideal Sewage i)i.posal
System at:
Ytly .a:wn
Type of Building
I)welling—No. of Bedroom:
Other—Type of Building
Other fixtures -.
Design Flow
Septic Tank—Liquid capacity
Disposal Trench—No.
Seepage Fit No
Other Distribution box
Percolation Test Results
Test Pit No. 1
Test Pit No. 2
J
Instaicr
Description of Soil
Size Lot Sq. feet
Expansion Attic ( ) Garbage Grinder (
Nn. of prrst,r, Showers ( ) — Cafeteria ( )
gallon) per person per day. Dotal daily Sow -_gallon:.
g;.11ons Length - \\idth Di:unete- _ Dept
to idPi
Total Length Total leaching area sq. L.
Diameter Depth below inlet Total leaching area
Dosing tank ( )
Performed by—.- -----
minutes per inch Depth of Test Pit
minutes per inch Depth of Test Pit
. . . .. . . . .. . . . Date
Depth to ground watr'
Depth to ground water_
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 SI of the State Sanitary Code— The undersigned further agrees not to place the system in
operation until a Certificate of Compliance has been issued by the board of health.9 n ,
Sid ' \ ?i .e� - ituJc A-w.£ 4113/9-7
Application Approved By id - - : - " llaft
Application Disapproved for the following reasons:_-- ------- ------------- ---- ------. --UUU----,-
Permit No
Issued
nat
/3,../_9.78
by
THE COMMONWEALTH OF MASSACHUSETTS
BOARD OF HEALTH
OF
Cnrrtifiratr of tbontpliaurr
THIS IS TO CERTIFY, That the Individual Sewage Disposal System constructed ( ) or Repaired
)
mmaarr
at
has been installed in accordance with the provisions of Article RI 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