Lot 5 Septic Application Permit & Plans CHECK OR FILL IN WHERE APPLICABLE
No..j:.:...._.
THE COMMONWEALTH OF MASSACHUSETTS
Faa.J
BOARD OF HEALTH
Appliratiun fur fli�pnsttl Thnrlth Tunstrurtinn 1rrmit
Application is hereby made for a Permit to Construct ( ) or Repair ( ) an Individual Sewage Disposal
System at:
Location.Address or Lot No.
Address
Installer�� Address
Type of Building Size Lot Sq. feet
Dwelling—No. of Bedrooms Expansion Attic ( ) Garbage Grinder ( )
Other—Type of Building No. of persons Showers ( ) — Cafeteria ( )
Other fixtures
Design Flow / gallons per person per day. Total daily flow gallons.
Septic Tank—Liquid capaci ,.._.:__.gallons Length Width Diameter Depth
Disposal Trench--No. Width Total Length Total leaching area / '..sq. ft.
Seepage Pit No Diameter Depth below inlet Total leaching area sq. ft.
Other Distribution box ( ) Dosing tank ( )
Percolation Test Results Performed by Date
Test Pit No. I 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
Agreement:
The undersigned agrees to install the aforedescribed Individual Sewage Disposal System in accordance with
the provisions of:'i 5 of the State Sanitary Code—The a ersigned f tl:er agrees not to place the system in
operation until a Certificate of Compliance has been issued nth bard gf%
f. a th.
Signed
Application Approved By
Application Disapproved for the following reasons'
Date
Permit No - s'
Date
Date
Issued.
Date
THE COMMONWEALTH OF MASSACHUSETTS
BOARD OF HEALTH
OF
QTrrtifiratr of Qtomplianrr
THIS IS TO CERTIFY, That the Individual Sewage Disposal System constructed ( ) or Repaired ( )
by .. . .. _. . __. . . . .._ ... .
Installer
...
at
has been installed in accordance with the provisions of TITLai 5 of The State Sanitary Code as described in the
application for Disposal Works Construction Permit No dated
THE ISSUANCE OF THIS CERTIFICATE SHALL NOT BE CONSTRUED AS A GUARANTEE THAT THE
SYSTEM WILL FUNCTION SATISFACTORY.
DATE Inspector
No
THE COMMONWEALTH OF MASSACHUSETTS
BOARD OF HEALTH
OF
%wnaat a urlw QInnatrurtion Permit
FEE
Permission is hereby granted
to Construct ( ) or Repair ( ) an Individual Sewage Dispdsi System
at No Street
as shown on the application for Disposal Works Construction Permit No Dated
Board of Health
DATE
FORM 1255 HOBBS & WARREN. INC., PUBLISHERS
" MGS File No. 79_56
•
HLRE APPLICABLE
CHECK OR PILL IN
No
THE COMMONWEALTH OF MASSACHUSETTS
BOARD OF HEALTH
CITY kOuTu i; TCti
\pplirutuiii fur D;5 pmia I Itlu •j(y (TL?1I3'stu tins iJermiti
Application is hereby made for a Permit to Construct (X ) or Repair ( ) an Individual 4,.
System at:
Clement Street
Lot No. 5 Rhc'eler Subdivision
Victoria It. Wheelerea� 353 Lurts Pit :berme') tiotttarnton, ^1
o...« 998 Westrar ,a ry
Omasta Bros. , Inc. i,ton-. c ;fort ^ntot�, 1
installer _lbtrcav
Type of Building Size f.ot cq feet
Dmelliug— No. of Bedrooms Expansion Attic ( ) Garbage Grinder
Other—Typo of Building _ No of per>on= Shovers ( ) — Cafeteria (
Other ftxtures
Deign Flour :moons per pear -t per day. Total daily [law gallon-
Seiaic Tank-— Liquid capacity gallons Length VVidtlt Diumctc-
Disposal Trench—No. Width Total Length To
Seepage Pit NO Diameter Depth balmy inlet "Iota
Other Distribution box ( ) Dosing ian.: ( )
Percolation Test Results Performed by, 1•12 cha el G. Sutrenant, PE Date 04/28/78
Test Pit No. I 4 a 3 minutes per inch Depth of Test Pit 8•0• Depth to grown! tc.te 6• 5•
Test Pit -Co 2 2 •0n. test per inc.!' Depth of fast °it 7• 5• Depth to ground °•
0" - 6" Tonsoil - Dark brown
Description of Soil
6" - 22" Subsoil - Podium Brown
22" - 96" Sand-Clay - Grey - ..ediu:
to Loosely Packed
Nature of Repairs or Alterations—Answer when applicable
Agreement:
The undars igned agrees to install the aforedeeribed Individual Sewage Disposal Syutem !u ..ace yr
the provisto:) or Al ticlu NI o: the slab. Sanitary Code—The undersigned iurtber agrees not to place the 5y_.em in
operation until a Certificate of Cotnpli: nee has been issued by the board of health.
Signed
Date
Date
Date
Application Approved By
Application Disapproved for the following
eason••
by
Permit No Issued
mm
THE COMMONWEALTH OF MASSACHUSETTS
BOARD OF HEALTH
.OF.
(,tcrfifirute of aitimpliann,
THIS IS TO CERT1EY, That the Individual Sewage Disposal System constructed ( ) or Repaired
at
has Lem inball c'r._utce with Ih,. -nom of.A title XI of The State Sanitary Code as described in the
apthcnion Werks Comtm,yian r ._ it So dated
THE iSr,UANCE OF THIS CEw T:F:CATE SHALL NOT BE CONSTRUED AS A GUARANTEE TEAT TH=_
SYSTEM WILL FUNCTION 541 ISFACTORY.
DATE Inspector _
i