Lot 4 Septic Application & Permit CHECK OR FILL IN WHERE APPLICABLE
No
THE COMMONWEALTH OF MASSACHUSETTS
BOARD OF HEALTH
Application for BBisposnl OF arks (Qonstrurtion hermit
OF
FEE
Application is hereby made for a Permit to Construct (I) or Repair
System at: y 4 4
L ti prA.ld
Ownery
Installer
Type of Building
Dwelling—No. of Bedrooms
Other—Type of Building
Other fixtures
Design Flow Cp _gallons per person per day. Total daily
Septic Tank—Liquid ca]Rjacity yLi gallons Length Width .1
Disposal Trench— No. Width �f✓z1 Total Length SO
Seepage Pit No Diameter Depth below inlet
Other Distribution box ( ) Dosing tank ( )
Percolation Test Results Performed by
Test Pit No. 1 minutes per inch
Test Pit No. 2 minutes per inch
ford
an Individual Sewage Disposal
or Lot Do.
Address
Address
Size Lot Sq. feet
3 Expansion Attic ( ) Garbage Grinder (
No. of persons Showers ( ) — Cafeteria ( )
flow gallons.
Diameter Dc tph
Total leaching area 1.ZS...sq. ft.
Total leaching area sq. ft.
Date
Depth of Test Pit Depth to ground water
Depth of Test Pit Depth to ground water
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 NI of the State Sanitary Code—The undr ' ned further agrees not to place the system in
operation until a Certificate of Compliance has been issued b
Application Approved By
Sign
test
Application Disapproved for the following reasons
Permit No E. 't'
D:` l'r ti3
Date
Date
Issued
Date
THE COMMONWEALTH OF MASSACHUSETTS
Lr✓ BOARDOFHEALTH
OF /Paid,
rrtifirntr of Tv plianrr
by THIS IS TO
/ CEj� 7FY.,�� j
719t thr Individual Sewage Disposal System constructed (r ) or Repaired
at M it e L�C.F;+y G.6^^C_.
has been installed in accordance with the provisions of Article/ � .XI of The State Sanitary e as describe in the
application for Disposal Works Construction Permit No /b._ dated /i 0"-'
THE ISSUANCE OF THIS CERTIFICATE SHALL NOT BE CONSTRUED AS A GUARANTEE THAT THE
SYSTEt WILL FUNCTION SATISFACTORY.
DATE x1. Z 12.�Xa Inspector
U
No.11 �L
THE COMMONWEALTH OF MASSACHUSETTS
BOARD OF HEALTH
Pisan/3 i ifflTrkn nnntrurtinn drrmit
Permission ishereby granted 'ttr ^'
to No (J ) or R pair lean 199,d,ividual Se age Disposal System
at No As.2L .. . .S.{itlk
street
as shown on the application for Disposal Works Construction LeDnit No. 1..�.._°.�. . Dated
f Da
, an e-e l
Board of He h
FEE
DATE
0e4. 15 IG63"
FORM 1255 HOBBS IN WARREN. INC.. PUBLISHERS