113 Septic Application Permit & Perc Tests //'
2
/2 ) 3YS
�nl-
CHECK OR FILL IN
No...fl.�"Z
FEE
THE COMMONWEALTH OF MASSACHUSETTS
BOARD OF HEALTH
) pplirtttinn fur ilispusttl iurkt' Qlunstrurtiun 1rrmii
Application is hereby made for a Permit to Construct (Kin Repair ( ) an Individual Sewage Disposal
System at:
Installer
Type of Building
Dwelling—No. of Bedrooms
Other—Type of Building
Other fixtures
I /3
or Lot No.
Address
Address
Size Lot Sq. feet
Expansion Attic ( ) Garbage Grinder ( )
No. of persons Showers ( ) — Cafeteria ( )
Design Flow �} gallons
Septic Tank—Liquid capacity{1 gallons
Disposal Trench—No. Width
Seepage Pit No Diameter
Dosing tank ( )
per person per day. Total daily flow gallons.
Length Width._._.._.__ Diameter D�gpth
Total Length Total leaching area 7 4 sq. ft.
Depth below inlet Total leaching area sq. ft.
Other Distribution box
Percolation Test Results
Test Pit No. I
Test Pit No. 2
Performed by Date
minutes per inch Depth of Test Pit Depth to ground water
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 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 of health. yam/ a
Application Approved By
Si
v
it Y //es -
Date
Application Disapproved for the following reasons'
Permit No
Issued
l-f _/1E3
Date
by
at
has been installed in accordance with the provisions of Article XI of The State Sanitary Code as described in the
application for Disposal Works Construction Permit No dated 2/e-/
THE ISSUANCE OF THIS CERTIFICATE SHALL NOT BE CONSTRUED AS A GUARANTEE THAT THE
SYSTEM IWILL FUNCTION SATISFACTORY.
DATE I 7,. Inspector
' '414 r -K51
THE COMMONWEALTH OF MASSACHUSETTS
BOARD OF HEALTH
4 , /
;1
rrtifictite nf Olunfpliantr
THIS IS Tay, GERI:1171S Thi the Individual Sewage Disposal System constructed ( ) or Repaired tV
I6. (f:rtf:,, ,, Installer
No
THE COMMONWEALTH OF MASSACHUSETTS
BOARD OF HEALTH
OF ()17-:>* -
Einpnlittl ,113nrfin Tom union tirrmit
Perrnissio hereby granted -1,1,
FEE
to Construct or Reixtir ) an Indiarl Sewage Disposal System
at No
' 1 as k,' / 3
Street
as shown on the application for Disposal Works Construction Rex d Na -/
f ,V.
Board of HealtERI
DATE
ROAR 1255 HOBBS & WARREN. INC.. PUBLISHERS
Board of :Italth
City flail
' c.-tha.tptc=, u.,,...s .
gentlemen:
I have mode cevsdal seveolasion sC>- d sample
at land belonging te Donald Wst ._ Itcaved a re W t e_ly. .s
n=_.t 3 .reet ` . . ert}ar' tr:n
For I r net t _ retl i :sego- ' th'ss teots, oleaut ?.
ha attached sketch showing the er1 n5 ix,eatlans ot the percola-
tion tests t9xen and a to yo last week, plus the
1
m-ar.:.1.,
:
n of the new tat k n t ,Oer ?ti . This .tsh stows setup r his proposed. plus the percolation ies t iueai the percolation rite at each hole,
If y pve. i osts rs -i
tea ing tht r inrc atton. • to-
quirt any 1 thet explanation , please do not hes:_'nte :.c coctact
me.
e,?
Mr, Donald (air
"MO Chaster field E,c l
Leads , !Istsachtn
Alva: Ho -ciay . Orb.
Registered Ss'11tarlar
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