Lot 5 Septic Appication & permit 1976 CHECK OR FILL IN WHERE APPLICABLE
No /.ie
THE COMMONWEALTH OF MASSACHUSETTS
FEE_/ n a
BOARD OF HEALTH
��Ni.l OF
Applirattun f,a Ui5pnsal darks uustrurtiuu Permit
Application is hereby made for a Permit to Construct (r' ) or Repair ( ) an Individual Sewage Disposal
System at:
or Lot No.
Address.
Type of Building Size Lot Sq. feet
Dwelling—No. of Bedrooms Expansion Attic ( ) Garbage Grinder ( )
Other—Type of Building .. No. of parson- Shower ( ) — Cafeteria ( )
Other fixtures
Design Flow gallons per person per day. Total daily slow gallons.
Septic Turk—Liquid capacity 9 g'Jlons Length Width Diameter Depth
Disposal Trench—No. Width Total Length Total leaching area sl. ft.
Seepage Pit No Diameter Depth below inlet Total leaching,arcs sq. ft.
Other Distribution box ( ) Dosing tank ( ) / 400 tit Cdot oni tp.ea
Percolation Test Results Performed by Date
Test l'it 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 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 will
the provisions of Article XI of the State Sanitary Code—The undersigned further agrees not to place the system rn
operation until a Certificate of Compliance has been issued by the board of health.
Signed e
Application Approved By .f7 CE CletQ '1•Tf
Application Disapproved for the following reasons
nom
i 4.7,6
V nme
by
at
has been installed in accordance with the provisions of \rtide 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
THE COMMONWEALTH OF MASSACHUSETTS
BOARD OF HEALTH
OF
Cnrrtifirate of (iCnmplinnrr
THIS IS TO CERTIFY, That the Individual Sewage Disposal System constructed ( ) or Repaired ( )
I tia�ne.
THE COMMONWEALTH OF MASSACHUSETTS
, BOARD F HEALTH
No.%i4 n
-�u.. _. OF .
. a
dinptmal prim Q? iudrurtinu Prrmit
Permission is rehy granted - - —. AbAr
to Construct r R�rair ) sn Indivtdiyj- e`age Disposal System
at No 9_.a - strew
as shown on the application for Disposal Works Construction Perm o e Date
?1�
�oa�[ Ilcallh
DATE
FORM 1255 HOBBS & WAPR EN. INC.. PUBLISHERS