Lot 2 Septic Application & Permit CHECK OR FILL IN WHERE APPLICABLE
I
No....at 6..
THE COMMONWEALTH OF MASSACHUSETTS
SOARD. OF HEALTH
`A./1.4 - OF /9 44-
1
Annlirttinn for flis}lnsixl Lurks [onstrurtinn Permit
FEE .
Application is hereby made for a Permit to Construct (r ) or Repair ( ) an Individual Sewage Disposal
System at:
dd,z"
or Lot No.
3 5 e. Address t /J, 71red
-
InstWicr
Type of Building Size Lot Sq. feet
Dwelling— No. of Bedrooms Expansion Attic ( ) Garbage Grinder ( )
Other—Type of Building No. of persons Showers ( ) — Cafeteria ( )
Other fixtures gallons.
Design Flow _5(1 gallons per person per day. Total daily flow
Septic Tank—Liquid capacity]aagallons Length Width Diameter Depth A
Disposal Trench—No Width Total Length Total leaching area 7 0 t4q. ft.
Seepage Pit No Diameter Depth below inlet Total leaching area sq. h.
Other Distribution box ( ) Dosing tank ( )
Percolation Test Results Performed by Date
Test Pit No. 1 minutes per inch Depth of Test Pit Depth to ground water
Test Pit No. 2 minutes per inch Depth of Test Pit Depth to ground water
Description of Soi
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 XI of the State Sanitary Code—The undersigned further agrees not to place the system in
operation until a Certificate of Compliance has been iisued by ie board of heal•~
Application Approved By tl U 1 li:
Application Disapproved for the following reasons'
Permit No
Issued
Date
la ) 46
Date
THE COMMONWEALTH OF MASSACHUSETTS
BOARD OF HEALTH
OF .. (`'hi, .ztifZ.,r
atrrtifiratr of font plianrr
THIS IS TQ CERTIFY, That the Individual Sewage Disposal System constructed (< or Repaired ( )
by ,C:is iis ifse‘d ! ,-
at
has been installed in accordance with the provisions of Article RI of The State Sanitary C de as described yt the
application for Disposal Works Construction Permit No ,.>"i.Lie dated '-
THE ISSUANCE OF THIS CERTIFICATE SHALL NOT BE CONSTRUED AS A GUflANTEE THAT THE
SYSTEM WILL FUNCTION SATISFACTORY.
Inspector -{..4:;I.f(f)i.,(' 2/, �i 1 Ffti j
THE COMMONWEALTH OF MASSACHUSETTS
BOARD OF HEALT
yy S
Elinpoot,$ rr•orl wtrurtion tirrmit
nL
FEE
Permissiol ' hereby granted �.�.��'
to Construct, d of Rviaair ., ) an Igdividual Se e D sposal System
at No S so-cer t g �� / /
as shown on the application for Disposal Works C o n s t r u c t i o q,-P e r a n�i p t Nolosr
.I. aced. .—q"N • ( i
DATF
FORM 1255 HOBBS & WARREN. INC.. PUBLISHERS
Bo(rd out