Misc. Lot 15 Septic Application & Permit IN WHERE APPLICABLE
IECK OR F
No 9).°
THE COMMONWEALTH OF MASSACHUSETTS
C $OARD OF HcALTH
OF .74
Appliratinn fur ilispnstti Works Clnnsirur#inn hermit
Application is hereby made for a Permit to Construct (14 or Repair ( ) an Individual Sewage Disposal
System at:
FES
1F :
Cation.Address.1 .. or Lot No.
Address
m.ta:er/ . r , . 10 Address N
Type of Building Size Lot -ST—Mr
Dwelling—NJ'af-Bed*eants Expansion Attic ( ) Garbage Grinder ( )
Other—Type of Building No. of persons Showers ( ) — Cafeteria ( )
Other fixtures gallons
Design Flow gallons per person per day. Total daily flow
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 inset 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 Pk 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 TITLE 5 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
Signed
Application Disapproved for the following reasons:_.
permit No r! ,
Issued (/t 71? /
Date
by
at `-_.--
has been installed in accordance with the pro son, i..W 5 of The State Sanitary Code a es¢ d in the
dated ... _..
application for Disposal Works C�oinsWrEtion Permit No -,.--. --�THE ISSUANCE OF 7N/4-CERTIFICATE SHALL NOT BE CONSTRUED AS A GUARANTEE THAT THE
SYSTEM WILL FUNCTION SATISFACTORY.
DATE Inspector
(aµX../._Mme^ La- t-ri Q,a L✓7Ad 24c-et-MI
LAG
4 THE,COMMONWEALTH O MASSAC SETTS 0
/�-pv^°„„',",,'. BOARD HEALTH Kti0-� °^
OF
Qirrtifirtttt of Qlnmplittnrr
THIS IS TO CERTI , That the Individual Sewage Dispos stem constructed- ) or Repaired ( )
No
THE COMMONWEALTH OF MASSACHUSETTS
BOARD OF HEALTH
OF
Oittpnsttl IlloritritTuttOrurtion f trmtt
Permission is hffreby granted ^' `
to Construct (IJjol Repair ( ) an Individual Sewage Disposal Sys 31
at No .. —._ street
as shown on the application for Disposal Works Construction Permit
DATE
47 /
FORM 1255 HOBBS & WARREN. INC.. PUBLISHERS
FEE '
/� 'f /
_iifoard of Health