Lot 11 Septic Appications ECK OR FILL IN WHERE APPLICABLE
No....6..zCF...S_....._
THE COMMONWEALTH OF MASSACHUSETTS
BOARD OF HEALTH
OF
FEE..� 7
1ppliratinn fur Qispnsal Winks CIunstrurtiun hermit
Application is hereby made for a Permit to Construct (/5) or Repair ( ) an Individual Sewage Disposal
System at:
.4 aliag. .. j 1//
.',6J/yLtata tro{yy@/y�(t;��(/q/K}, or Lot No.
°•�^kflner.. Address
Address
Type of Building Size Lot Sq. feet
Dwelling—No. of Bedrooms Expansion Attic ( ) Garbage Grinder ( )
Other—Type of Building No. of persons Showers ( ) — Cafeteria ( )
Other fixtures
Design Flow ,,tt gallons per person per day. Total daily flow gallons.
Septic Tank—Liquid capacitOW ...gallons Length Width Diameter Depth
Disposal Trends—No. Width Total Length Total leaching area—ja.e.d.sq. ft.
Seepage Pit No Diameter Depth below inlet Total leaching area sq. ft.
Dosing tank ( )
Performed by_.._...._...._._._________.__.__.____...___. Date
minutes per inch Depth of Test Pit Depth to ground water
minutes per inch Depth of Test Pit Depth to ground water
Other Distribution box
Percolation Test Results
Test Pit No.
Test Pit No. 2
Description of Soil
Nature of Repairs or Alter
nswer when applicable
Agreement:
The undersigned agrees to install the aforedescrihed individual Sewage Disposal System in accordance with
the provisions of TIT Lid 5 of the State Sanitary Code—The undersigned further agrees not to place the system in
operation until a Certificate of Compliance has been,$ssue e boar Health.
Application Approved By
I� 9.re
Hate
Application Disapproved for the following reasons
by
Permit No..ea-T.51--
Issued...
THE COMMONWEALTH OF MASSACHUSETTS
BOARD OF HEALTH
OF
Qtertifiratr of Ctnmplianrr
THIS IS TO CERTIFY, That the Individual Sewage Disposal System constructed ( ) or Repaired ( )
Installer
at
has been installed in accordance with the provisions of Ti?i._ 5 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.
DATF Inspector
S/.1
._I
C
C Type of Building
Size °
3 O 3 S feet
U- Dwelling—No. of Bedrooms Expansion t he ( ) Slec Got Gathage Grinder 9(
v
W Other—Type of Building _.J;.4AIC rf No. of persons Showers ( ) — Cafeteria ( )
R.
No
THE COMMONWEALTH OF MASSACHUSETTS
BOARD OF HEALTH
Cu. - OF k(OCTNpY(pi_o Y.f
Application for L1itfisual Mliork, (riots fritrIimt mutt#
Application is hereby made for a Permit to Construct ( ) or Repair ( ) an Individual Sewage Disposal
System Q at:
4Uf T S E F Co4O , ,t/( T/
YJ.0 CaEC'a E. 60--)X70 r(
Addres-s
Other Gxt tires
W Design Flow 50 gallons per person per day. Total daily flow ...500
tsJ
• Septic Tank—Liquid capacity/000 gallons Length Width Diameter
Disposal Trench--- No Width Total Length
'-' Total Ruching area
5 Seepage Pit No Diameter . 1)epth below inlet Total leaching area
▪ Other Distribution box (11 Posing tank ( )
▪ Percolation Test Results Performed by d', O'4 TES
. Test Pit No. i /6 7 minutes p:r inch
f=+ Test Pit No. 2 minutes per inch
FS
O Description of Soil (a"LV A/1
V .2
Depth
400
L)
u
Depth of Test Pit 7 O
I)eptb of 'rest Pit Depth to ground water
gallons.
sq.ft.
sq. ft.
Date VC"- S_/9.]/
Heigh fn ground water 'UO. G:i�),
Co =Lc 7
Nature of Repairs or Alterations—Answer when applicable
S4vo.
'r1°°
Agreement:
The undersigned agrees to install the aforedescribed Individual Sewage Disposal System
the provisions of Article NI of the State Sanitary Code—The undersigned further agrees not to
operation until a Certificate of (on'i 1'ancc has been issued by the hoard of health.
Signed
Application Approved By
Application Disapproved for the following reasons
in accordance with
place the system in
Date
Dae
Date
Permit No Issued
ohs
by
THE COMMONWEALTH OF MASSACHU5ETT6
BOARD OF HEALTH
OF
QIrrtificulr of frimpliitatrr
THIS IS TO CERTIFY, That the Individual Sewage Disposal System constructed ( ) or Repaired ( )
In,t Wei
at
lets been installed in accordance with the provisions of .Article XI of The State Sanitary Cale as described in the
application for Disposal Works Construction Permit No doted
THE ISSUANCE OF THIS CERTIFICATE SHALL NOT DE CONSTRUED AS A GUARANTEE THAT THE
SYSTEM WILL FUNCTION SATISFACTORY.
DATE
vvvvv
CHECK OR FILL IN WHERE APPLICABLE
No....1..1..6L FEE..l.2 t
THE COMMONWEALTH OF MASSACHUSETTS
BOARD OF HEALTH
OFxU C,
Appliratiun fur lispnsal r;c arks fnunntrurtiun tirrtnit
Application is hereby made for a Permit to Construe
System at:
(
or Repair ( ) an Individual Sewage Disposal
t..s 11
—r yl Lot No.
rAddress
Installer Address
of Building Size Lot Sq. feet
Dwelling—No. of Bedrooms Expansion Attic ( ) Garbage Grinder ( )
Other—Type of Building No. of persons Showers ( ) — Cafeteria ( )
Other fixtures - - - -
Design Flow gallons per person per day. Total daily flow gallons,
Septic Tank—Liquid capacityJS$allons Length Width Diameter Depth
Disposal Trench—No. Width Total Length Total leaching area 1G..a...-aq. ft.
Seepage Pit No Diameter Depth below inlet Total leaching area sq. ft.
Other Distribution box ( ) Dosing tank ( )
Percolation Test Results Performed by Date
Test Pit No. 1 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 with
the provisions of Article XI of the State Sanitary Code—The undersigned further agrees not to place the system in
operation until a Certificate of Compliance has been issued byth board of health.
Application Approved By ,�.. c 2G.f .x 7 Qi -- J2/
1 om
Application Disapproved for the following reasons
Permit No 1 / s
Issued
pp Date
// 77
•
by
THE COMMONWEALTH OF MASSACHUSETTS
BOARD OF HEALTH
OF
f2rrtifirate of fdumplianre
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 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