Misc. Septic Application & Permit 2 CHECK OR FILL IN WHERE APPLICABLE
'
No '4 —Vte'
THE COMMONWEALTH OF MASSACHUSETTS
BOARD OF HEALTH
OF .
/asa'Fss....
Appliratiun fur &inpusttl Murkn,Cnnnntrurfintt Permit
Application is hereby made for a Permit to Construct (✓S or Repair ( ) an Individual Sewage Disposal
A .'O/1 L 1 TL
System at:
canon•Addres
ost � I d
Installer Ad
ress
Type of Building d c% Size Lot Sq. feet
Dwelling—No. of Bedrooms Expansion Attic ( ) Garbage Grinder ( )
Other—Type of Building )( No. of persons 62 Showers ( ) — Cafeteria ( )
Other fixtures /
Design Flow 0.- !c0 lions per person per day. Total daily flow gallons.
Septic Tank-Liquid capacity../ Length Width Diameter Depth
Disposal Trench— N Width Total Length Total leaching area aq. ft
Seepage Pit No f Diameter Depth below inlet Total leaching arealQ
Other Distribution box ( ) Dosing tank ( ) (/t
Percolation Test Results Performed by 'g-f"'c- -�"" - Datef../A
Test Pit No. 1 -0— minutes per inch Depth of Test Pit J Depth to ground water�H471.e-
Test Pit No. 2 minutes per i h Depth of Tes Pit Depth to ground water
¢3 ' � z5e ..[A .... ... JI /f
Description of Soil
5 r i�'7.✓-c """^` (A1't'e - d-en "e)
or wt No.
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
p p by the board of health.
operation until a Certificate of Compliance s been issued Signed ,,
i :ZA��...K�, ( - r
Application Approved By /2^ Bard Ya `�
Application Disapproved for the following reasons'
Permit No
Date
Issued
Date
by
THE COMMONWEALTH OF MASSACHUSETTS
BOARD OF HEALTH
OF
Olirrtifiratr of Tamplianrt
THIS IS TO CERTIF/' Th.t ''e Indivt u' Seyvr isposal System constructed (V) or Repaired
stater
at
has been installed in accordance with the pro,isions f TITEEj 5� i
The State Sanitary Code as described in the
application for Disposal Works Construction Permit No p dated 17./?`?" rfir
THE ISSUANCE OF THIS CERTIFICATE SHALL NOT BE CONSTRUED AS A GUARANTEE THAT THE
SYSTEM WILL FU�µIy�CTION SAT�I?FACTORY.
DATE >"v 4 2e 11-6149 Inspector vi-c-
No
THE COMMONWEALTH OF MASSACHUSETTS T
BOARD OF HEALTH
OF
Jispossl
Permission is h by granted
to Construct ( r Repair[( ) on Individual Sewage Disposal System
at No Street
as shown on the application for Disposal Works Construction Permit no��
Dated
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