Misc. Lot 10 Septic Application & Permit CHECK OR FILL IN WHERE APPLICABLE
No cr.
THE COMMONWEALTH OF MASSACHUSETTS
BOARD OF HEALTH
St) of '�}l ti!a4-Cep
Applirattatt far fTizptlliat E urkti QtDttntrurtinn Permit
Application is hereby made for a Permit to Construct ( ) or Repair ( ) an Individual Sewage Disposal
System at:
the-L. bied41.414..al
or Lut Nu.
14[ O Address
FEE.7�.
a i 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 How gallons.
Septic Tank—Liquid capacity/ .. . '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. p
Other Distribution box ( ) Dosing tank ( ) /add +%f� k1+d'T
Percolation Test Results Performed by Date U
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
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 NI 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.
Application Approved By
Application Disapproved for the following reasons
Signed
Ziv !ah___LYZI
Ddte
Permit No..1..1 Q
Date
9/kV'
IMUCCI.... _.. ...%lr'...7,.
Date
by
THE COMMONWEALTH OF MASSACHUSETTS
BOARD OF HEALTH
OF
(itrrtifiratr vi (anmplianrr
THIS IS TO CERTIFY, That the Individual Sewage Disposal System constructed ( ) or Repaired
)
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 ,�f-A{i`R'77r 4yI
Bispnsal lI,ork (In at rn_
rtinn tirrmit
Permission eby granted 4.e:7uf 6-iroaeaer
to Construct ( ) or Repair ( ) an vrdual Sewage Disposal System
at No Coins- 1cLes.::.: (,.ti.:(lr
FEE 7D: cl
Street
as shown on the application for Disposal Works Construction Pe lit No 11/F 1 --,'Dated._Zt:_I ,_�S'.L{.Board of II• h
DATE
FORM 1255 HOBBS & WARREN. INC.. PUBLISHERS