Lot 9 Septic Application & Permit CHECK OR FILL IN WHERE APPLICABLE
THE COMMONWEALTH OF MASSACHUSETTS
BOARD F HEALTH
Applirntinn fur Dismal
FEE
nrlto Cnnnntrurtinnrrmit
Application is hereby made for a Permit to Construct ( ) or Repair
System at: t:..
Gt
Loratiou9tseldryss
owner
Installer
Type of Building
Dwelling— No. of Bedrooms Expansion At
Other—Type of Building
Other fixtures
Design Flow "fitq,, .gallons
Septic Tank—Liquid capacity gallons
Disposal Trench—No. Width
an Individual Sewage Disposal
or Lot No.
Address
Address
Size Lot Sq. feet
c ( ) Garbage Grinder ( )
Showers ( ) — Cafeteria ( )
a-d
No. of persons
per person per day. Total daily flow
Length Width Diameter
Total Length Total leaching area
hi
gallons.
DGp h...
sr" sq. ft.
et Total leac ng area sq. ft.
Seepage Pit No Diameter Depth below inl
Other Distribution box ( ) Dosing tank ( )
Percolation Test Results/ Performed by
Test Pit No. 1 YJ minutes per inch Depth of Test Pit
Test Pit No. 2 minutes per inch Depth of Test Pit
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
the provisions of Article XI 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 board q health. l /7
/ "'"'t
-Signed
Application Approved By
Application Disapproved for the following reasons
7te✓. i jG.L
Date
Permit No
Issued y/.a- /
6 r:
Date
by
THE COMMONWEALTH OF MASSACHUSETTS
BOARD OF HEALTH
OF i
._ /6'_""
j _ ".t,(' t. ry
hlrrtifuate of To liana
THIS IS Tp CERTIFY; That the IFdividual Sewage Disposal System constructed (r ) or Repaired ( )
at
has been installed in accordance with the provisions of Article XI of The State Sanitary Code as described, ip the
52 R.11 dated /Lev• Y �_/j a l
application for Disposal Works Construction Permit No ,'-
THE ISSUANCE OF THIS CERTIFICATE SHALL NOT BE CONSTRUED AS A GUARANTEE THAT THE
SYSTEM WILL FUNCTION SATISFACTORY. - ..
DATE :I;".t • ,.....Lit 7 Inspector.. F: 1f Ly ,v err"
Installer
No
THE COMMONWEALTH OF MASSACHUSETTS
BOARD OF HEALTH
;4/4" of
FEB
Iiopnottl Marko C!tono rurtion Permit
PermissiotiChereby granted
to Constripat$ pj Rep.?t ( ) au Individuij Sewage Disposal System
at No _;.... 7 t•;y e' L.-e, c,d-i
Street
as shown on the application for Disposal Works Construction Permit No err Dated_ j
al
Bo of t
f I! alt
DATE
FORM 1255 HOBBS & WARREN. INC.. PUBLISHERS