Misc. Lot 9 Septic Application & Permit CHECK OR FILL IN WHERE APPLICABLE
Na..4J .
FEE.
1.17 L' R
THE COMMONWEALTH OF MASSACHUSETTS
,BOARD O7F/ HEALTH
v4c`6. r,/ OF.. FC'%-C�Ty�c,(y..f1rn
1pptiratiun fur Ili-opium! N,urks Tetnitrnrtiun 1 rrmit
Application is hereby made for a Permit to Construct (') or Repair ( ) an Individual Sewage Disposal
System at:
It
Lent Ad r or Lot No.
f f hq°r`�^' ( )T.
Installer
Type of Building y 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 yyt gallons per person per day. Total daily flow gallons.
Septic Tank—Liquid capacitykya n gallons Length Width Diameter Depth
Disposal Trench—No. Width Total Length Total leaching area g:.Q.dsq. ft.
Seepage Pit No Diameter Depth below inlet Total leaching area sq. ft.
) Dosing tank ( )
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
Address
°tl
Address
Other Distribution box
Percolation Test Results
Test Pit No. I
Test Pit No. 2
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 rees not to place the system in
operation until a Certificate of Compliance has .ued by the»oar.
Application Approved By
Si
Application Disapproved for the following reasons'
Permit No
Date
Issued..<: •.,t^._r..- -L...../.-`S..%
V Date
by
THE COMMONWEALTH OF MASSACHUSETTS
BOARD OF HEALTH
OF
Qlrrtifiratr of Qtnmplianrr
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
1
fit At . OF fIn7- `rithF'p.FE27
No._�� ,f
FEEL:1 4 ')
/. �isposa
Fig/ arks .ftuu t nrtinn Permit
Permission,ys hereby granted )7"443 {:IC. r..CY':.:%IL 7
to Construct (✓ ) or Repair ( ) an Individuate ewage pisppswl System
at No d^i`+ r .<.�.. !�.:Y1;,,a. ■ fir
Street r ! 1 /
as shown on the application for Disposal Works Construction Pertrvt No r , .%� Dated /1 .......
a y+ �I
yY'^ �:::• •I Board of Health
DATE
FORM 1255 HOBBS & WARREN. INC.. PUBLISHERS