Lot 4 Septic Appication & permit 1976 CHECK OR FILL IN WHERE APPLICABLE
THE COMMONWEALTH OF MASSACHUSETTS
BOARD OF HEALTH
OF Peratyri
Appliratintt fn finpuSttl Wurk5 Tottatrurtion llrrutit
Application is hereby made for a Permit to Construct (V) or Repair ( )
System at:
01.4347-0rl RJ:K
an Indio:dual Sewage Disposal
or Lot No.
Addreha
Astrist hQ-Ip.CA:
Size Lot Sq. feet
Expansion Attic ( ) Garbage Grinder ( )
No. of person Showers ( ) — Cafeteria ( )
Type of Building
Dwelling—No. of Bedrooms
Other—Type of Building
Other fixtures
Design Flow gallons pc
Septic Tank—Liquid capacit 4_grillons
Disposal Trench—No. Width Total Length
Seepage Pit No Diameter Depth below inlet
Other Distribution box ( ) Dosing tank ( ) JQ✓0,
Percolation Test Results Performed by
Test Pit No. 1 minutes per inch
Test Pit No. 2 n:mutes per inch
person per day. Total daily flow gallon..
nth Width I)i:uneter Deed•.____.._...
Total leaching area sg_ ft.
Total leaching trea sq- it
041 tiets d .4...a
Date
Depth of Test 1'it Depth to ground water
Depth of Tex Pit Depth to ground water
Description of Soil
Nature of Repairs or Alterations—Answer when applicable
Agreement: .
The undersigned agrees to install the aforedescrihed Individual Sewage Disposal System in accordance with
the provisions of Article NI 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 the board of health.
Signed �7 p �
`Yf"" (/ // Dmc
Application Approved By
Application Disapproved for the following reasons'
Permit No. 7o 9
Issued art-ICE 46
Date
by
at..
has hcen In;tallcd in accordance with the provisions of Article SL 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
THE COMMONWEALTH OF MASSACHUSETTS
BOARD OF HEALTH
OF
Trriifiraie of klomplianrr
THIS IS TO CERTIFY, That the Individual Sewage Disposal System constructed ( ) or Repaired
meaner
No7O f
THE COMMONWEALTH OF MASSACHUSETTS
BOARD OF HEALTH
OF Y�_ U -
h ptioa •
U orka fron�f_rurtion 1rrmit
Permission is rchy granted -O! M HO�j- •to Constru`cp(t t) oeRepajr ) an Individu: coewage Disposal System p>
at No O(.c�'� '�d f4 }t;19:>" ..).._ -iiff.L' s�:e.� �j / }/y,��i �J !/..'6
70( Dated. - ;
as shown on the application for Disposal Works Construction rn No._
FEE
DATE
FORM 1235 HOBBS Be WARREN. INC.. PUBLISHERS