Misc. Lot 12 Septic Application & Permit CHECK OR FILL IN WHERE APPLICABLE
No t
THE COMMONWEALTH OF MASSACHUSETTS
BOARD OF HEALTH
/ a .1
FEE.. I..•� e
Andiratinu fur flinpnsttl ifturkn (nn tztrurtinu 3jrrmit
Application is hereby made for a Permit to Construct (Y) or Repair ( ) an ludil ideal Sewage Disposal
System at: ,...i"-..7. r
(
Location-AcidrSs or tat No.
f_ +.. w .
-Owner� .Y',+f Address
mInner 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 Retures
Design Flow / gallons per person per day. Total daily flow gallons.
Sept ic 'C:utk-Liquid capacityfq. 2tgallons Length '1.VW: Diameter— .......... Deepr1
Disposal Trench—No. Width Total Length Total leaching area /( DC sq. ft.
Seepage Pit No Diameter Depth below inlet Total leaching area sq. ft.
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
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 sued d of hfalth.
Signed_
/ / -
Application Approved By
VU Date
Application Disapproved for the following reasons'
Permit No L.' r '
Issued._
Date
Date
by
THE COMMONWEALTH OF MASSACHUSETTS
BOARD OF HEALTH
OF
hlrrtifiratr of Tnmpliaurr
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 . ... . . ...... . . . .. .. . . __ _... .. __ ....-
No (" �1
Permission
to Construct
at No
THE COMMONWEALTH OF MASSACHUSETTS
BOARD OF HEALTH
A.i.T of `; �.c_. a✓,..
!ioposat,il�nrlto QI natrurtion lrrmit
rehy granted - C.12 Girl=
or Repair ( ); an Individual Sewagf Disposal SystLrm
Street
application for Disposal Works Construction Permit No (irk./ Dated
IA
FEE_.. J -- V
as shown on the
DATE
FORM 1255 HOSES 5 WARREN INC.. PUBLISHERS
Board of health