Lot 13 Septic Appications CHECK OR FILL IN WHERE APPLICABLE
No...17 1/
THE COMMONWEALTH OF MASSACHUSETTS
BOARD OF /HEALTH
�y
OF r -:
Apptiratinn for topcoat i i'!who 'dnnntrurtinn Vaunt
Yea._/.5l a a
Application is hereby made for a Permit to Construct (V or Repair
System at:
Type of Building
Dwelling—No. of Bedrooms
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 capacity/ 'gallons Length Width Diameter Depth
Disposal Trench—No Width Total Length Total leaching area fo
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
an Individual Sewage Disposal
/_3
or Lot
Address
Address
Size Lot Sq. feet
Expansion Attic ( ) Garbage Grinder ( )
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
Application Approved By e yed by the board of health.
PP PP Y
Signed '�Y1::11.��b' '�-red _.x T-
r-
,,J.operation until a Certificate of Compliance has been issued
—
h. ..LY.. Q,�c_lf�2.1 y }�-�p D.E../97/
it
Application Disapproved for the following reasons
Permit No 1-L..1 1-1
by
THE COMMONWEALTH OF MASSACHUSETTS
BOARD OF HEALTH
OF . . ..
Crrtifirtttr of Otumplittnrr
THIS IS TO CERTIFY, That the Individual Sewage Disposal System constructed
or Repaired
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
CHECK OR FILL IN WHERE APPLICABLE
No
•
THE COMMONWEALTH OF MASSACHUSETTS
BOARD OF HEALTH
CITE OF dLo era Ali prod
Application fur lis}Tuna! 3tlnrttn Qlnnsfrnrfinn Permit
Application is hereby made for a Permit to Construct ( ) or Repair ( ) an Individual Sewage Disposal
System at:
&EIS ,QIT ecAO A/0 , i3
Loc�lro,r. n
acQgsag F4f TOt)
owner
or Lot No.
Address
Installer Address /O SQO
Type of Building `_3 Size Lot ,e Sq. feet
Dwelling—No. of Bedrooms 4 Expansion Attic ( ) Garbage Grinder ( )
Other—Type of Building ..CAFE No. of persons S Showers ( ) — Cafeteria ( )
Other fixtures
Design Flow So gallons per person per day. Total daily flow 460 gallons.
Septic Tank—Liquid capacity/000gallons Length Width Diameter Depth
Disposal Trench—No. Width Total Length Total leaching area 48 sq. ft.
Seepage Pit No Diameter Depth below inlet. Totl1ea 'ling area sq. ft.
Other Distribution box (A Dosing tank ( Tot
P� t.
Percolation Test Results Performed by 4 a£053, Hooray A`-f(r Date Ay,Oc Z /2Z/
y......
Test Pit No. 1 ..4 Q minutes per inch Depth of Test Pit & Depth to ground watcr..VD,_G..1[a
Test Pit No. 2 minutes per inch Depth of Test Pit Depth to ground water
Description of Soil Ca .44IIEK...:......( LQA.!i y 5 ' .$4& V Wi rel 7246E n
G QAVe.l, Z f!M.c........G e 15AN0 LQ Tr/ &'r7E 51r.1% /UMI!
Nature of Repairs or Alterations—Answer when applicable 4. ,% O /) .I
Agreement: /y���
The undersigned agrees to install the aforedescribed Individual Sewage Disposal System in accordance with
the provisions of Article N I 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 hoard of health.
Signed
Date
Date
Date
Permit No Issued
Doe
Application Approved By
Application Disapproved for the following reasons-