Misc. Lot 8 Septic Application & Permit CHECK OR FILL IN WHERE APPLICABLE
THE COMMONWEALTH OF MASSACHUSETTS
h'aa.
1� A °
BOARD OF HEALTH
dpplirntinn fur Tispnsnl r,r;arks fltnnstrnrtinn Permit
Application is hereby made for a Permit to Construct (/ ) or Repair ( ) an Individual Sewage Disposal
System at: t ,
LP LoegIett-nqd .- or Lot No.
rkai el^ t
ot Address
no.t+u rr
Installer
Type of Building
Dwelling—No. of Bedrooms
Other—Type of Building
Other fixtures
Design Flow .a'�..}}.(� gallons per person per day. Total daily flow �.Q..C4 gallons.
Septic Tank—Liquid capacity, .5.gatlons Length Width Diameter Depth
Disposal Trench—No. Width...) .22 Total Length Total leaching area kiS%.Q...sq. ft.
Seepage Pit No _Diameter Depth below inlet Total leaching area sq. ft.
Dosing tank (, )
d b 9ryprk.t'K
n
3
Address
Size Lot Sq. feet
Expansion Attic ( ) Garbage Grinder (kr.
No. of persons Showers ( ) — Cafeteria ( )
Other Distribution box
Percolation Test Results
Test Pit No. 1....Wwr
Test Pit No. 2
Performed by
minutes per inch
minutes per inch
.) Date
Depth of Test Pit Depth to ground water
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 undersi ed further agrees not to place the system in
operation until a Certificate of Compliance has be r issued by the ealth.
Si / Sa
Application Approved By 4.IP:(t'&1 s -Y ,J
Application Disapproved for the following reasons- ii v
t
Date
Z
Date'
Permit No 1 -'
Issued._:iddd ij-a.L.1./... `
r t.
by
THE COMMONWEALTH OF MASSACHUSETTS
BOARD OF HEALTH
OF
alittifirntr of fltomplinnre
THIS IS TO CERTIFY, That the Individual Sewage Disposal System constructed ( ) or Repaired
)
Installer
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
THE ISSUANCE OF THIS CERTIFICATE SHALL NOT BE CONSTRUED AS A GUARANTEE THAT THE
SYSTEM WILL FUNCTION SATISFACTORY.
DATE Inspector
THE COMMONWEALTH OF MASSACHUSETTS
BOARD OF HEALTH
OF
No.`" ..i rt_. 0
Illisoonal
Permission ereby granted 2:/,. t
to Construct
Permission
Repair ( ) an In_dividrilf Sewage Disposal System
at No G-# G.? .f: f
..`t' F-t 1'rty,�..__,.t,m Street y
as shown on the application for Disposal Works Construction Perrtut No /..LS Dated yd_.i J....y.
' ',A-1.4.7.,:.
Boanr&&flee
rr;
nrko fdonstrurtionrrmif
FEEj4.-4
DATE
FORM 1255 HOBBS & WARREN. INC.. PUBLISHERS