Lot 3 Septic Application & Permit .L IN WHERE APPLICABLE
CHECK OR F
No 16
THE COMMONWEALTH OF MASSACHUSETTS
BOARD OF HEALTH
OF
Fax
Application for Disposal Fr,nrhs Toustrurtinn rrmit
Application is hereby made for a Permit to Construct ( ) or Repair ( ) an Individual Sewage Disposal
System at i
..7 Cite-4 (U-e
t L tSddresq.��,�W/�
g1.t4 t..� ' s�'/ I Address
1rta�r-*++LO1.i* rl
installer ze L
Type of Building Size Lot Sq. feet
Dwelling— No. of Bedrooms 3 Fxpansion Attic ( ) Garbage Grinder ( )
Other—Type of Building No of persons Showers ( ) — Cafeteria ( )
Other fixtures
Design Flo 1, 1 gallons per person per day. Total daily flow gallons.
Septic Tank—Liquid capAcity.u.a gallons i jaellgth Width r Diameter Depth.
Disposal Trench—No.....) Width_.A.LL.e_-- Total Length .J 4 Total leaching area 3 7 sq. ft.
Seepage Pit No Diameter Depth below inlet Total leaching area .. . sq. ft.
Other Distribution box ( ) Dosing tank ( )
Percolation Test Results Performed by Date
Test Pit No. I 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
or Lot No.
Description of Soil
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 red further agrees not to place the system in
operation until a Certificate of Compliance has been sued' -
Application Approved By
Si
J
J\ ca.. !off"/ % E
Dam
Application Disapproved for the following reasons
li
Permit No. 4-4
Date
Issued tic C . I✓ I 7 F3"
Date
THE COMMONWEALTH OF MASSACHUSETTS
f BOARD OF HEALTH
L "**. OF / r> n '7
Qrrtifiratr of Qtomplianrr
THIS IS To ERTIJ'Y, Tlitt t1F Individual Sewage Disposal System constructed (free--) or Repaired ( )
by }2-4r ; .+.tfl
has been installed in accordance with the provisions of Articig I of The State Sanitary C as described in the
application for Disposal Works Construction Permit No it I dated AS. �I F�
THE ISSUANCE OF THIS CERTIFICATE SHALL NOT BE CONSTRUED AS A GUARANTEE THAT THE
SYSTEM ILL FUNCTION SATISFACTORY. 4,64-4
DATF '�'Yl.•....7.;...i.94 h Inspector )J x -er%
at
Installer
No..16l
THE COMMONWEALTH OF MASSACHUSETTS
BOARD OF HEALTH
OF. ff 7)..4.Sytr{zt
s ( tlt #rttrtiun Permit
Permission 1 e eby granted
to ConSn t rgrr epair ) an Individ 7gI eeage Disposal System
at No __ 'O /!�E fi�6
FEE
Street
as shown on the application for Disposal Works Construction Per No i
Board of Irca1N
ted Re, /S I ykJ
DATE
FORM 1255 HOBBS & WARREN. INC.. PUBLISHERS