Misc. Lot 11 Septic Application & Permit CHECK OR FILL IN WHERE APPLICABLE
No a '
THE COMMONWEALTH OF MASSACHUSETTS
B %OF OARD OF HEALTH
Applirntinn fur iliNumil Matte O[nnstrurtinu lJrrniit
FEE 4"
Application is hereby made for a Permit to Construct ( or Repair ( ) an lndiridual Sewage Disposal
System at:
L alqq..-AddreC)
?. rI 'La'
nor-r-1
Installer (r
d.
U 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 q gallons per person per clay. Total daily Flow gallon
Septic 'lank—Liquid capar itt%pt5C'gall ons Length Width Diameter Depth
Disposal Trench—No. Width Total Length Total leaching area_ !O 0 s. ft
Seepage Pit No Diameter Depth below inlet Total leaching area sq. it
Other Distribution box ( ) Dosing tank ( )
Percolation Test Results Performed by Date
Test Pit No. I 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
or Lot No.
Address
Description of Soil
Nature of Repairs or Alterations—Answer when applicable
Agreement:
The undersigned agrees to install the aforedescribed Individual Sewag• 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 beet,issyed by the beard of he-Ith.
Signed
•
te
Application Approved By - F''u'r....._../.
2,1e
Application Disapproved for the following reasons'
Permit No._-L^=(1
Issued
Date
Date
by
THE COMMONWEALTH OF MASSACHUSETTS
BOARD OF HEALTH
OF
f2rrtifirate of lltnmplianrr
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
No r� JG � � � Fes. �:. d%
Dispasttl iliforka 7Cnnnstrnctinn Permit
Permission i ereby granted /{.z 1-2� - =f.:.sHF'+�
to Construcst (. ) or Repair ( ) am jndivid 1 iSe age D,$posal Vystern
at No —tLf3'_.1.Q
as shown on the application for Disposal Works Construction Permit _t G
�7 No. /ion.a-ot tI.almi/�
DATE
FORM 1255 HOBBB & WARREN. INC.. PUBLISHERS