10 Septic Application & Permit 1976 HERE APPLICABLE
CHECK OR FILL IN
No
Fax
._0
THE COMMONWEALTH OF MASSACHUSETTS
BOARD OF HEALTH
- -a OF
Appltrutimt for fliR{Iaual lurks Tott0trurtinu Vrrutit
Application is hereby made for a Permit to Construct ( ) or Repair ( ) an 1ndit idual Sewage Disposal
System at:
rr .:(2.;.0-i - or Lot No.
s (
e e,
%?...�t'di' Installer r'� Address
Type of Building Size Lot Sq. feet
Dwelling—No. of Bedrooms Expansion Attic ( ) Garbage Grinder ( )
Other—Type of Building No. of persun; Showers ( ) — Cafeteria ( )
Other fixtures
Design Flow gallons per person per day. Total daily flow gallons.
Septic Tank—Liquid capacity gallons Length Width Diameter - Depth
Disposal Trench—No. Width Total Length Total leaching arc- sq. ft.
Seepage Pit No Diameter Depth below inlet Total leaching urea sq. ia.
Other Distribution box ( ) Dosing tank ( )
Percolation Test Results Performed by Date
Test Pit No. 1 minutes per inch Depth of Test Pit Depth to ground water
Test Pit No. 2 minutes per inch Depth of Test Pit Depth to ground water
Description of Soil
Nature of Repairs or Alterations—Answer when applicable_
-5/d
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 undersigned further agrees not to place the system in
operation until a Certificate of Compliance has beemissued by the board of health.
Signed
ter
Application Approved By
Application Disapproved for the folio reasons-
Permit No
Date
Issued i ' /
,i'' tf_de2...1..9-7.Gt
THE COMMONWEALTH OF MASSACHUSETTS
BOARD OF HEALTH
OF
rrtifiratr of (bout liana
C
T O CERTI�j Ytv. at thgaIndividual Sewage Disposal System constructed ( ) or Repaired
by L1 . Gl.fstnt fr,ve.
at UN�
has been installed in accordance with the provisions of Ar
application for Disposal Works Construction Permit No
THE ISSUANCE OF THIS CERTIFICATE SHALL
SYSTEM WILL FUNCTION SATISFACTORY.
DATE_.._._ ul _l. , ) 916
)
ticd XI of The State Sanitary C de as described in the
/s dated__.: aY' -4X
NOT BE CONSTRUED AS A GUS RANTEE THAT THE
Inspector..LC/..%`-"J=j"L....;;;; _ace!,cf:en.2
THE COMMONWEALTH OF MASSACHUSETTS
BOARD OF HEALTH
BOARD, {.}-Laic
pig � Ya� OF yl
No
Bin}Tnnalnrltn nnnfrttrtinn permit
4.444<4 Permission is hereby granted -
.../ ti
to Construct ) or Repair ( ) an Individual Sewage Disposal System
at No J A {',4 a4 a '— Street
as shown on the application for Disposal Works Construction Per,ylit io -.1 sue,/ D:Sted L<,14�tt!:.-?-- '..�%
J7:**14 Jy. f�
Board of Health
ter
FEE..RA) AJ
DATE
FORM 1255 HOSES & WARREN. INC_ PUBLISHERS