Lot 6 Septic Appication & permit 1976 CHECK OR FILL IN WHERE APPLICABLE
THE COMMONWEALTH OF MASSACHUSETTS
FEE pc Q
tt�BOARD�fOF� HEALTH
(6,C to- _. OF !.((t'hGit
Applirutiun-fur Uispusul 3 urtznnstrurium limuit
Application is hereby made for a Permit to Construct ( ) or Repair ( ) an Indic idual Sewage Disposal
System at: /� 1 4 z t /f
bF–JS^.-��'�C'Y area s
or Lot Nn.
Address
Ailireis
Type of Building V Size Lot Sq. feet
Dwelling—No. of Bedrooms Expansion Attic ( ) Garbage Grinder ( )
Other—Type of Building .. No. of person-. Showers ( ) — Cafeteria ( )
Other assures
Design Flow gallons per person per day. Total daily flow gallons.
Septic Tank—Liquid capacith 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. ft
Other Distribution box ( ) Dosing tank ( ) J Q Q d �l ra of / (V.per
Percolation Test Results Performed by Date a
Test Pit No. I atinutes 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 with
the provisions of Article S1 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
Application Approved By
Application Disapproved for the following reasons
Permit No
71/
Daft
Date
Date
Issued
Date
by
THE COMMONWEALTH OF MASSACHUSETTS
BOARD OF HEALTH
_.
OF
Trrtifirate of kiumplitturr
THIS IS TO CERTIFY, That the Individual Sewage Disposal System constructed ( ) or Repaired
Installer
at
has been installed in accordance with the provisions of :Article Xl of The State Sanitary Code as described in the
application for Disposal }Corks Construction Permit No dated
THE ISSUANCE OF THIS CERT!FTCATE SHALL NOT BE CONSTRUED AS A GUARANTEE THAT THE
SYSTEM WILL FUNCTION SATISFACTORY.
DATE Inspector
THE COMMONWEALTH OF MASSACHUSETTS
BOARD OF HEALTH
// ...... OF... rl3Prt+r'9 FEE.l+J-r.G.0
Pthpnntt Tpnrks Tnttstrurtinit Permit
Permission is rehy granted eden
to Construc ) or Repair ( ) n Individu ($�age Disposal System
�� a
at No # %/ - 't1=-}-.. street
as shown on the application for Disposal Works Construction Per ij D
DATE
FORM 1255 HOBBS & WARREN, INC,. PUBLISHERS
Board of
/5797,6