Misc. Lot 16 Septic Application & Permit CHECK OR FILL IN WHERE APPLICABLE
THE COMMONWEALTH OF MASSACHUSETTS
BOARD OF HEALTH
err)/ OF ..N4BlHAn Via-44 0 `N--'- -
pliratian far 3ilinpaattl Works Cnanatrmtinn 1ermit
Application is hereby made for a Permit t
System at:
CGte 5 Mc' OQ , Runt?
Location•Address
GECRUS eA&E.
Owner Address
(V) or Repair ( ) an Individual Sewage Disposal
Lot No.
/s& Cc. ,n.,3L
Installer Address
Type of Building Size Lot ± t f.A.4..34 By.-&...t
Dwelling—No. of Bedrooms 4 3A RN Expansion Attic ( ) Garbage Grinder (✓)
Other—Type of Building 55l&4_.f "1 No. of persons 8 Showers ( ) — Cafeteria ( )
Other fixtures
Design Flow 55- gallons per person per day. Total daily flow &Ez.5 gallons.
Septic Tank—Liquid capacity1.s0Ggallons Length/2.4" Width._Lv.6 .. Diameter Depth.5S-
Disposal Trench— No. it- Width 3' Total Length...30' Total leaching area.72.3 sq. ft.
Seepage Pit No Diameter Depth below inlet Total leaching area sq. ft.
Other Distribution box (✓) Dosing tank
Percolation Test Results Performed by IC '° Fiku v
--zoDate 5—ciC.4Q/
Test Pit No. 1....v1 minutes per inch Depth st P /Q.'.. Depth to ground water ppQ"r
Q
Test Pit No. 2 a minutes per inch Depth of est Pr . Jo' Depth to ground water .Q"
Description of Soil
Q7.s - so, L - (O4RSE. 5AMc
Nature of Repairs or Alterations—Answer when applicable
Agreement:
The undersigned agrees to install the aforedescribed Individual Sewage Disposal System
the provisions of TITLE 5 of the State Sanitary Code—The undersigned further agrees not to
operation until a Certificate of Compliance has been issu by the Board of health.
S,m,ed.... .w- ,yr
Application Approved By
in accordance with
place the system in
//-3 -13
Date
I1 —g 5-3
Dat
Application Disapproved for the following reasons
Permit No
Date
Issued.
by
THE COMMONWEALTH OF MASSACHUSETTS
BOARD OF HEALTH
OF
QTertiftrate of TompIiatue or Repaired ( )
THIS IS TO CERTIFY, That the Individual Sewage Disposal System constructed ( ) P
Instants
at
has been installed in accordance with the provisions of TITLE
application for Disposal Works Construction Permit No
THE ISSUANCE OF THIS CERTIFICATE SHALL NOT
SYSTEM WILL FUNCTION SATISFACTORY
DATE
5 of The State Sanitary Code as described in the
dated
BE CONSTRUED AS A GUARANTEE THAT THE
Inspector
THE COMMONWEALTH OF MASSACHUSETTS
BOARD OF HE TH /
OF 11411'12
l-C
n Permit Revise,/ 1- ,))
3�ispnsttl i,�nrkn�nnntrurf '�
Permission`'is hereby granted GeL2t�e--'- '�
to Construct (»e) or Repair ( ), an IndividCal. Sew ge Disposal System
at No C' s t,. ( Street
as shown on the application for Disposal Works Construction PermitLNo r Dated
i .Hoard of Heaih
Q
DATE Y'-
FORM 1255 A. M. StJLKIN, BOSTON