Misc. Septic Application & Permit 1 •Wniri
6,
CHECK OR FILL IN WHERE APPLICABLE
No (e fa
THE COMMONWEALTH OF MASSACHUSETTS
BOARD OF HEALTH
OF
Appliratiun for°flispusttl Marko @tun,utrurtiun Vrrutit
Application is hereby made for a Permit to Construct ( ) or Repair (Vl en ludic ideal Sewage Disposal
System at:
Installer
Type of Building Size Lot 4q. feet
Dwelling—No. of Bedrooms Expansion Attic ( ) Garbage Grinder ( )
Other—Type of Building .. No. of persons Showers ( ) — Cafeteria ( )
Other fixtures
Design Flow gallons per person per day. Total daily flow gallon.
Septic Tan.—Liquid capacity gallons Length Width Diameter Depth
Disposal Trench—No. Width Total Length Total leaching area sq. ft.
Seepage Pit No Diameter Depth below inlet Total leaching area sq. h.
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 Ovate
Description of Soil
Nature of Repairs or .Alterations—Answer when applicable._.L.£ta kid d2ner
Agreement:
The undersigned agrees to install the aforedescribed individual Sewage Disposal System in accordance with
the provisions of Article N1 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 he board of health.
Si nepd� . .. L ' }� p
Application Approved By ��f JAG L(:_(y2p!CCga[p71-. _ N.n�br��/_-3
Application Disapproved for Ube following reasons'
Permit No
GG�� � � 7 Date
Issued .712V 6t .L473
Date
by
THE COMMONWEALTH OF MASSACHUSETTS
BOARD OF HEALTH
OF
hirrtifiratr of Toutplittnrr
THIS IS TO CERTIFY, That the Individual Sewage Disposal System constructed ( 1 or Repaired
)
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.
DATF Inspector
by
THE COMMONWEALTH OF MASSACHUSETTS
BOARD OF HEALTH
OF
Trrtifiratr of lbnmplianrr
THIS IS TO CERTIFY, That the Individual Sewage Disposal System constructed ( ) or Repaired ( )
Installer
at
Las 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./c.C)_L
THE COMMONWEALTH OF MASSACHUSETTS
BOARD OF HEALTH
FEE,:-.) J
Ouipnnol 3lnrk5 iiLLnt3strurtinu Prrmit
ti }.
Permission is hereby granted}( t' lC fJ.ti.__ s f
r -
to Construct !) or/Repajr 4✓) an Individual Sew g@‘Dispos l ystem
at No y t#itt.1 'Ats1e 47z•--
street
as shown on the application for Disposal Works Construction Perrot No iL Dated i ,x Iii
zitT
El( rA of IIct
DATE
FORM 1255 HOBBS & WARREN. INC.. PUBLISHERS