Lot 8 Septic Application & Permit NB
THE COMMONWEALTH OF MASSACHUSETTS
BOARR,OF HEgLTH
OF
Application for llinpo.sttl rU nrtc (lnnstrnrtinn f ermit
Application is hereby made for a Permit to Construct ) or Repair ( ) an Individual Sewage Disposal
System at: f'
Ft-
FEE
kDW< Aearess
Installer Size Lot Sq. feet
Type of Building
Dwellin g No. of Bedrooms , Expansion Attic ( ) Garbage Grinder ( )
Other—"l Type of Building No. of persons Showers ( ) — Cafeteria
Other fixtures
or Lot No.
Design Flow II��'',,{{
Septic Tank—Liquid capacityiiiOE..gallons a l evi Length gth width
Disposal Trench—No. __3 width . i Total Len -5 d
Seepage Pit No Diameter Depth below inlet
Other Distribution box ( ) Dosing tank ( )
Percolation Test Results Performed by
Test Pit No. 1 minutes per inch Depth of Test Pit
Test Pit No. 2 minutes per inch Depth of Test Pit
gallons per person per day. Total daily flow gallons.
Diameter D 4i
Total leaching area 3 /S sq. ft.
Total leaching area sq. ft.
Description of Soil
Date
Depth to ground water
Depth to ground water
Nature of Repairs or Alterations—.Answer when applicable
Agreement:
The undersigned agrees to install the aforedescribed Individual Sewage Disposal System in accordance with
-ianed further agrees not to place the system in
the provisions of Article XI of the State Sanitary Code—The
operation until a Certificate of Compliance has b-. ued b
Application Approved By
Si
Application Disapproved for the following reasons
.41d64.- •I) ! t 1-
Date
Permit No 1
Issued
Date
ot• jq(r3_
Date
THE COMMONWEALTH OF MASSACHUSETTS
BOARD OF HEALTH
di; OF. g, ` , t>7
ertifirttte of (gnilittnre
vy
THIS IS TO CERTIFY, That the Individual Sewage Disposal System constructed (tor Repaired
by )..itbric. "1"'`C-1
at
has been installed in accordance with the provisions of Article XI of The State Sanitary Cyde as .described in the
application for Disposal Works Construction Permit No �-J dated .�G G
THE ISSUANCE OF THIS CERTIFICATE SHALL NOT BE CONSTRUED AS A GUARANTEE THAT THE
Installer
SYSTEM WILL FUNCTION SATISFACTORY.
DATP ,elri . /g 19
DATE
No
Inspector
THE COMMONWEALTH OF MASSACHUSETTS
BOARD OF HEALTH
ilisilnntti 33nrl l CIntl tnlrtlntt Permit
Permission is erehy granted I j'-?'+ 7 1 ' '-•>l •�
to Construct ( ) or Egpair ( ) an Individual Sewage Disposal System
at No j,J q fi L1
FEE
Street %;
as shown on the application for Disposal Works Construction Permit No J Darted
Oa t
Board [ ealth
DATE
FORM 1 269 HOBBS & WARREN. INC.. PUBLISHERS