862 Septic Application & Permits 1970 CHECK OR FILL IN WHERE APPLICABLE
No lI
THE COMMONWEALTH OF MASSACHUSETTS
BOARD OF HEALTH
FEB/
Appliratinn for /Disposal iiieorks Totts#rurtiun hermit
Application is hereby made for a Permit to Construct (' ) or Repair ( ) an Individual Sewage Disposal
System at: -.�, _ /.
' ern , . . 2-7,11
or Lot No.
Address
Type of Building
Dwelling—No. of Bedrooms
Other—Type of Building No. of persons Showers ( ) — Cafeteria ( )
Other fixtures
Address
Size Lot Sq. feet
Expansion Attic ( ) Garbage Grinder ( )
Design Flow IDdd
Septic Tank—Liquid capacity gallon Length Width_.T
gallons per person per day. Total daily flow
Diameter Depth
Total leaching area.._r4.P 0 sq. ft.
Total leaching area sq. ft.
Disposal Trench—No. Widthc'•O Total Length 3
Seepage Pit No Diameter Depth below inlet
Other Distribution box ( ) Dosing tank ( )
Percolation Test Results Performed by
Test Pit No. 1 minutes per inch
Test Pit No. 2 minutes per inch
gallons.
Depth of Test Pit
Depth of Test Pit
Date
Depth to ground water
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 been isd hype boyd of health.
t Y C
SjgmZed C - :.-'. . �erf'Z.
'y
kl.P,.+ . .. G :'r . nom._,t' 6 ,�, ^r /_ualr/t:
Date
Application Disapproved for the following reasons
Application Approved By
all
Permit No
Date
Issued -> ,/i7
Date
THE COMMONWEALTH OF MASSACHUSETTS
BOARD OF HEALTH
of . /J .;7,!'L-:r, f:;
tartetifirate of fQoi'ttplianre
THIS IS ZO`CERTJ6�. That th Individual Sewage Disposal System constructed (or Repaired ( )
at
has been installed in accordance with the provisions of Article XI of The State Sanitary/code as described )n the
application for Disposal Works Construction Permit No 4'/f datedti ---_ .4_..'11 E
THE ISSUANCE OF THIS CERTIFICATE SHALL NOT BE CONSTRUED AS A GUARANTEE THAT THE
SYSTEM WILL FUNCTION SATISFACTORY. —)
Inspector-
THE COMMONWEALTH OF MASSACHUSETTS
BOARD OF HEALTH
Thnposn 3 nrk i Qannstrurtinn 1ermit
Permission j -hereby granted
to Construct (V ) or R air I
5r )as Indi(iduat;Sewage Dp System
_ 00 f. .
�i
as shown on the application for Disposal Works Construction Permit No. Dated - i /[--'
FEE! -' -U
DATE -2 /-J ,I ' 7 6
FORM 1255 HOBBS & WARREN. INC.. PUBLISHERS
Bo fa of Health