Lot 1 Septic Application & Permit CHECK OR FILL IN WHERE APPLICABLE
No....%=i
FEE
THE COMMONWEALTH OF MASSACHUSETTS
? _ .�-^-
BOARD OF HEALTH
✓'`r . OF 2 i.tq.
i}tpliratir t fur 38tspural e!url w Qdniiitrurtiun lrrmit
Application is hereby made for a Permit to Construct ( ) or Repair ( ) an Individual Sewage Disposal
System at: ,i,. :/ I
LA> .Mk:
1 o-a.Q t:o
fr _.n4:aaA Installer
Installer
Type of Building
Dwelling—No. of Bedrooms
No. of persons
3
or Lot No.
daress
Size Lot Sq. feet
Expansion Attic ( ) Garbage Grinder ( )
Showers ( ) — Cafeteria (
Other—Type of Building
Other fixtures
Design Flow A gallons
Septic Tank—Liquid capacity fa a gallons
Disposal Trench— No. Width
Seepage Pit No Diameter
Other Distribution box
Percolation Test Results
Test Pit No. 1
Test Pit No. 2
Description of Soil
per person day. Total daily flow gallons.
Length . . .d Width. '/,r/ Diameter Depth
Total eugth Total leaching area .7-5 sq. ft.
Depth below inlet Total leaching area sq. ft.
Dosing tank ( )
Performed by Date
minutes per inch Depth of Test Pit Depth to ground water
minutes per inch Depth of Test Pit 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 beeaisued by tl bo d o heith.
__S_—__("r%n ..) / o
Application Approved By ,yz`�-:fNj .“... . /A. +L]a?: tOr\ / ,t //FS
Date
Application Disapproved for the following reasons
Permit No /,
Issued..../hN
Date
% �Y
Date
THE COMMONWEALTH OF MASSACH USETTS
BOARD OF HEALTH
4}- or tiCrCT!'/i..p
rrtifirate of flompliuurr
THIS IS TOLCER 7FY, I/at t{be.Individual Sewage Disposal System constructed ('
" ) or Repaired ( )
by /r2a-* 3Iiltt >r!
Installer
at ,7=-} I (x(Cz-'.z ILLS
has been installed in accordance with the provisions of Article XI of The State Sanitary Cpde as described in the
application for Disposal Works Construction Permit No 1-5 -3 dated 7 Gam, /Q. ' // J
THE ISSUANCE OF THIS CERTIFICATE SHALL NOT BE CONSTRUED AS A GUARANTEE THAT THE
SYSTEM WJLL FUNCTION SATISFACTORY.
y�DJ l.5 ! 7 � ; s ( tie �f A -ui/ P
UgTg Inspector
No i ✓�
THE COMMONWEALTH OF MASSACHUSETTS
BOARD OF HEALTH
lam' 11. . OF "Lk PTA CiPri
3itipatial,ifiarks (Ru uitrurtinu Irrmit
Permission is hereby granted
to Constructor Rep?ir )/an Individual Sewage Disposal System
at No / L<ttY' LN*`-
street
as shown on the application for Disposal Works Construction Egrmit No / -3 Dated ' '-="
aj,.
DATE
FORM 1255 HOBBS & WARREN, INC.. PUBLISHERS