Lot 6 Septic Application & Permit CHECK OR FILL IN WHERE APPLICABLE
No
THE COMMONWEALTH OF MASSACHUSETTS
BOARD _O']] F yHEALTH
OF O,,GTi,IXnur'C'13i
FEE
Applirutisn for Disposal cr;inks (IIunstrurtinn Prrmit
Application is hereby made for a Permit to Construct (V or Repair ( ) an Individual Sewage Disposal
System at:
(JtL
r i or Lot N .
F #7 (✓.f A.. Address
td k6
Pw�
Installer
Type of Building
Dwelling—No. of Bedrooms
Other—Type of Building
Address
3 Size Lot Sq. feet
Expansion Attic ( ) Garbage Grinder ( )
No. of persons Showers ( ) — Cafeteria ( )
Other fixtures
Design Flow -td gallons per person per day. Total daily Flow 3 gallons.
Septic Tank—Liquid capacity, 4'e gallons Length Width Diameter Depth
Disposal Trench—No. Width Total Length Total teaching area i` 4 0 sq. ft.
Diameter 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
Seepage Pit No
Other Distribution box
Percolation Test Results
Test Pit No. 1
Test Pit No. 2
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 BI of the State Sanitary Code—The undersigned further agrees not to place the system in
operation until a Certificate of Compliance has been issued by the f card ofrhealth./
Application Approved 13
r.et./
tstorAtoen-On AF.
Application Disapproved for the following reasons
Date
Permit No -'t / 7
Issued'
THE COMMONWEALTH OF MASSACHUSETTS
BOARD OF HEALTH
OF
Q ertifirtttr of atntttplittnrr
THIS IS CERTIFs' ,That pie Individual Sewage Disposal System constructed (' ) o
SX r Repaired (
by rx<Ce1 Jia
has been installed in accordance with the provisions of Article X%7of The State Sanitary Cgde a described in the
application for Disposal Works Construction Permit No 4' / / dated- tx - 1'2 i %P.H
THE ISSUANCE OF THIS CERTIFICATE SHALL NOT BE CONSTRUED AS A GUARANTEE THAT THE
SYSTEM WILL FUNCTION SATISFACTORY. --�
DATP � :a _. u/ J. i�YF Inspector -_l}4 r._. /` ;bet r,"Wen
7
THE COMMONWEALTH OF MASSACHUSETTS
BOARD OF HEALTH
ilispoottf,giorko (!Innn nrtinn prrncit
Permissio hereby granted
✓?
to Construct .{L) or4Repair (icy-) an Indivp ual SeywggtDisposal System
at No
I'EE
as shown on the application for Disposal Worlcs Construction Eersttti o^- Dated�r U l , »7 B
DATE
FORM 1255 HOB05 & WARREN. INC.. PUBLISHERS
Street ! %
Board of Health A,