Lot 6 Septic Application & Plans CHECK OR FILL IN WHERE APPLICABLE
THE COMMONWEALTH OF MASSACHUSETTS
FEs/416
//uu�-/p��B4OARD OF HEALTH
lti!ii OF Z
Agplirtttinu for fiupuial Mork rrmit
Application is hereby made for a Permit to Construct
System at: O/' _a .-.p-
Type of Building
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 capacit/2.O..gallons Length Width Diameter
Disposal Trench —No. Width Total Length Total leaching area >(L.Q 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. 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
In
or Repair ( ) an Individual Sewage Disposal
or Lot No.
Address
Address
Size Lot Sq. feet
Description of Soil
Nature of Repairs or Alterations—Answer when applicable
Agreement:
The undersigned agrees to install the aforedescrihed Individual Sewage Disposal System in accordance with
the provisions of TIT L 5 of the State Sanitary Code—The undersigned further agrees not to place the system in
operation until a Certificate of Compliance has been issped by t .ard I;'alth.
Application Approved By
Application Disapproved for the folio
Si
9
S
by
Permit No....e -3.P
Issued_
Date
r_ .....,&Z5
THE COMMONWEALTH OF MASSACHUSETTS
BOARD OF HEALTH
OF
( rrtifirtttr of tdumplittnrr
THIS IS TO CERTIFY, That the Individual Sewage Disposal System constructed ( ) or Repaired
Installer
at
has been installed in accordance with the provisions of TITLE 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
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