272 Septic Application Permit & Compliance CHECK OR FILL.IN WHERE APPLICABLE
No feig?—
forts/a )_
THE COMMONWEALTH OF MASSACHUSETTS
BOARD OF/HEALTH
I}ipliratinn far 33iapnatti Narita Cnnnatrurtinn Permit
Application is hereby made for a Permit to Construct
System at: _
Type of Building
Dwelling—No. of Bedrooms
Other—Type of Building
Other fixtures
Design Flow
Septic Tank—Liquid capac
Disposal Trench—No.
Seepage Pit No
Other Distribution box
Percolation Test Results
Test Pit No. I
Test Pit No. 2
Description of Soil
or Repair (�an Individual Sewage D
posal
fir t:
t 7 gerer
Aaa«„
Address
Size Lot Sq. feet
SExpansion Attic ( ) Garbage Grinder (�-
No. of persons Showers ( ) — Cafeteria ( „L.
ity
gallons
gallons
Width
Diameter
per person per day. Total daily flow s-1? gallons.
Length Width Diameter Depth
Total Length Total leaching area sq. ft.
Depth below inlet Total leaching area sq. ft
Dosing tank ( )
Performed by Date
minutes per inch Depth of Test Pit /a Depth to ground water B%es-'
minutes per inch Depth of Test Pit Depth to ground water
a' Oa46 '^ 7'L rAltaa a'.4t.
Nature of epairs or Alterations q—�A(nswer yyhen ap,Plirable '° '_ 2-1°:41C-'46.
teel 20
AgreFment:
The undersigned agrees to install the aforedescribed Individual Sewage Disposal System in accordance with
the provisions of:IT Li] 5 of the State Sanitary Code— The undersigned further agrees not to place the system in
operation until a Certificate of Compliance has . issued by h boar of health. !/41/ )-^
Sig ;d
Application Approved By
Application Disapproved for the following reasons'
Permit No
9
Issued.
THE COMMONWEALTH OF MASSACHUSETTS
BOARD OF
HEALTH
@rrtifiratr ufof Ql&mpl
ntr
THIS ISiZoutelTIFT That the Ipdi iclual Sewage Disposal System constructed ( ) or Repaired (p)"
by at a 7 El Iawa ah
has been installed in accost-lane/ with the provisions of TITLE 5 oi The Stat anitary Code as de' ribed in the
application for Disposal Works Construction Permit No 9-F e- dated .51°ro eel—
THE ISSUANCE OF THIS CERTIFICATE SHALL NOT BE CONSTRUED AS A GUARANTEE THAT THE
SYSTEM WILL FUN/CTI N SATISFACTORY. � %
DATE �./.� ... + - Inspector ��Ht_
No X
THE COMMONWEALTH OF MASSACHUSETTS
BOARD OF HEALTH
OF ' ....-.
Wspton arkg. Tnnutrurtinn unlit
Permission is hereby granted
...<-. i/I;.j=' r
ncL
/6
Fae
to Construct ( ) or Repair (Lean Individual Sewagg Disposal System
at No
Sueet
as shown on the application for Disposal Works Construction Permit No%'/..:ri._ ... Da
J ti
r Board of IIth
DATE �. �
FORM 1255 HOBBS & WARREN, INC.. PUBLISHERS