Lot 5 Septic Application & Permit ERE APPLICABLE
CHECK OR FILL IN
Not PT 7
THE COMMONWEALTH OF MASSACHUSETTS
BOARD QF
Application for Dismal
Application is hereby made for a Permit to Construe
System at:
Inatanrr
Type of Building
Dwelling— No. of Bedrooms
Other—Type of Building
Other (rxtres
Design Flow
Septic Tank—Liquid capap}y, gall°
Disposal Trench—No. 7 Width
Seepage Pit No vise Diameter
F'EE
HEALTH
nrk (nnntrnrtinn jrrmit
(r) or Repair ( ) an Individual Sewage Disposal
or Lot No.
Address
3 Expansion Attic
No. of persons
Address
Size Lot Sq. feet
Garbage Grinder (
Showers ( ) — Cafeteria ( )
- J A
gallons per person per day. Total daily flow gallons.
ns ttl Length Wid .i Diameter D3Pt4i.a
Total Length Total leaching area sq. ft.
Depth below inlet Total leaching area sq. ft
Other Distribution box ( ) Dosing tank ( )
Percolation Test Result7 Performed by
Test Pit No. I minutes per inch
Test Pit No. 2 minutes per inch
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 XI of the State Sanitary Code—Tr and igned further agrees not to place the system in
operation until a Certificate of Compliance ha by the b-ar
0
Application Approved By
.O'C.y..T
Application Disapproved for the following reasons
4 rr
Date
Permit No 1
/76 gate
THE COMMONWEALTH OF MASSACHUSETTS
BOARD OF HEALTH
OF Il�y4.,nC 1461
arrtifirxte of (IIunt tianrr
THIS IS TO CE* 17 the Individual Sewage Disposal System constructed ( ) or Repaired ( )
(. t
installer
at
has been installed in accordance with the provisions of Article 4I of The State Sanitary forty as Lesfribed '4n the
application for Disposal Works Construction Permit No / I L dated...,}i.4
THE ISSUANCE OF THIS CERTIFICATE SHALL NOT BE CONSTRUED AS A dUAR NTEE THAT THE
SYSTEM %IILL FUNCTION SATISFACTORY.
\L" i 1/✓ ' %t f >• %� ? //y.
DATE t+ J
No I / /
THE COMMONWEALTH OF MASSACHUSETTS
BOARD F H ALT
OF
Bintinnal- n tte6,Trymteettrtiott lPrrutit
Permissiorvi(hcreby granted
to Construct (J=) or Re ai rvidml.Sewage Disposal System
tv-t-T y g {-€..� $ y
at No rt / I a°{' 7 /�� i
FEE
as shown on the application for Disposal Works Construction--Pep No _ '
DATE
FORM 1255 HOBBS & WARREN. INC.. PUBLISHERS
Board of ma