Misc. Lot 13 Septic Application & Permit No .i
THE COMMONWEALTH OF MASSACHUSETTS
BOARD OF HEALTH
Pppliratiun fur Eispusal i r arks�f6nnstrnrtinn Permit
Application is hereby made for a Permit to Construct ( ) or Repair ( ) an Individual Sewage Disposal
System at: ,,((..-..
j�. l ..A dFe or Lot Ne.
Lrc Ibu'�kddl�s �l��
FEE
Address
(l.l Owngr ep
Installer Address
Size Lot Sq. feet
Type of Building
Dwelling—No. of Bedrooms Expansion Attic ( ) Garbage Grinder ( )
P
Other—Type of Building
No. of persons Showers ( ) — Cafeteria ( )
Other fixtures �(j gallons.
Design Flow .5 4 gallons per person per day. Total daily flow
Septic Tank—Liquid capacity/c;t.i.a..gallons Length Width ` Diameter Depth ft.
Disposal Trench—No Width._c .d. Total Length..,:..? Total leaching aarea.t.ri.'f.a...sq.sq.ft.
Seepage Pit No Diameter Depth below inlet g
Other Distribution box (%o Dosing tank ( ) Date
Percolation Test Results Performed by
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
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 been sued by the board,of health.
Signed '
Application Approved By
Application Disapproved for the following reasons
Permit No
by
THE COMMONWEALTH OF MASSACHUSETTS
BOARD OF HEALTH
OF
`tdertifirafe of (knn4pliaiue
THIS IS,TO CEJZTIFP, Tiyat the Individual Sewage Disposal System constructed for Repaired ( )
/ Installer
at _ ...h.. ..-•
has been installed in accordance with the provisions of Article XI of The State Sanitary .ode as described in the
application for Disposal Works Construction Permit No 7 '4 dated.../Cavil ea2i. 47/
THE ISSUANCE OF THIS CERTIFICATE SHALL NOT BE CONSTRUED AS A GUARANTEE THAT THE
SYSTEM W!LL FUNCTION SATISFACTORY.
`' ;l r* (Mi
DATE - I ,' I ' a.yyf Inspector .
No //
THE COMMONWEALTH OF MASSACHUSETTS
BOARD OF HEALTH
Disposal ri,arks QQpnstrnrtinn hermit
Permission ' ereby granted
FEES:
to Construct « ) :or Repair ( „ ) an,kt4ividual Sewage Disposal System
at No
street r / � ;. 7
as shown on the application for Disposal Works Construction Permit„No.; - l Dated..' ([.:.:...2..:;._!.%L.1
DATE
FORM '255 HOBBS & WARREN. INC., PUBLISHERS
Board of Heal?
CHECK OR FILL IN WHERE APPLICABLE
No
-7 o - 7o
THE COMMONWEALTH OF MASSACHUSETTS
Fax
BOARD OF !HEALTH
v , I,
OF „.ir .13-1` te
Application nr thpnnat irks onotrurtion Prrntit
Application is hereby made for a Permit to Construct ( \,0 or Repair ( ) an Indh idual Sewage Disposal
System at:
Si T.:
....frocar::Address or Lot ico.
s.tj A 4
Owner Address
Installer
Type of Building
Dwelling—No. of Bedrooms 4
Other—Type of Building No. of persons
Other fixtures
Address
Size Lot /LA:I.:Z.5g. feet
Expansion Attic ( ) Garbage Grinder ( )
Showers ( ) -- Cafeteria ( )
Design Flow
Septic Tank—Liquid capacity
Disposal Trench—No
gallons per person per day. Total daily flow gallons.
gallons Length Width Diameter Depth
Width Total Length Total leaching area
Seepage Pit No Diameter epth below, inlet Total leaching area
Other Distribution box ( ) Dos' ( )
(-)Percolation Test Results Performed by L. .. Date..1.1
Test Pit No. (..zr minutes per inch/flepth of Test Pit '" FtePth to ground waterna../ o
Test Pit No. 2 /C
minutes per inch Depth of Test Pit Depth to ground water
sq. ft.
sq. ft.
,-- -- r
Description of Soil. 4..t.-4.-.s. _a t.. ' .z...k.,..k A • -4
a
i...i-4 .-04-0 X.{ 0 ° -1-
-
4-E-7-,‘
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 been issued by the board of health.
Signed
Data
Date
Date
Application Approved By
Application Disapproved for the following reasons
Permit No Issued
by
THE COMMONWEALTH OF MASSACHUSETTS
BOARD OF HEALTH
OF
attrtifirate of M ntplianre
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 FEE
Disposal
r:r;
nrks flinnstrurtinn jgrrmit
Permission is hereby granted
to Construct ( ) or Repair ( ) an Individual Sewage Disposal System
at No
Street
as shown on the application for Disposal Works Construction Permit No Dated
Board of Health
DATE
FORM 1255 HOBBS h WARREN. INC.. PUBLISHERS