Lot 17 Septic Appications No
THE COMMONWEALTH OF MASSACHUSETTS
Firs .
BOARD OF HEALTH
Cllr OF UCt'TT) t#e'lpiotl
Application for li pne,Id Wnrttn (lt;tiitr lrtintl V3rrutit
Application is hereby made for a Permit to Construct ( ) or Repair
System at:
t1.(..._.G:Ec z&EI i.3CFP(T..l
u
ci Type of Building
U. Dwelling—No. of Bedrooms
C.. Other—"f}pc of Building —.F.(3NC(d No. of persons
Other fixtures
Design Flow _ SG gallons per person per day. Total daily flow fOO
CG Septic Tank—Liquid capacity./C.OD:gallons Length Width
an Individual Sewage Disposal
//t. /7
.lose,.ss
Expansion Attic
4
Size Lot /' 6-St Sq. feet
Garbage Grinder (
Showers ( ) • - Cafeteria ( )
— Disposal p _1I Trench—Nn. Width
Seepage Pit No Diameter
7. Other Distribution box (4 Posit
Percolation MI Results Performed by
Total I.cngth
i)epth below inlet
ig tank ( )
E. //4/C c'E/
Test Pit No. 1./.53 minines per inch
C.. Test Pit No v mioutrs per inch
0
O
u
Description of Soil
Uimuelcr tenth
Total Ten Ali rag arca..4Qo
Total lcaC:ing area
Depth of Test i'it e'e ea
Depth of 'lest Pit
gallons.
q. ft.
q. ft.
Date.?FC't c /97/
Depth to ground water
Depth to ground eater a,
/2 %06791 /'4." ck-wiEL.
Nature of Pepairs ar Alterations
--Answer when applicable
Agreement:
The undersi
the provisions bl
operation until
ed agrees to install the aforedescribed Individual Searage Disposal System in accordance with
tide .K I of the State Sun u} Code--The under signed further agrees not to place the system in
;fit-waft of Compliance has been issued 1 y the board of health.
Signed
Application Ap roved By
Application Disapproved for thr following ra7s' Is'
Permit No
Date
Date
Date
Issued
Dam
by
at
has been installed in acccrdance the provisions of :ft title NI of The State Savi'ary Code as described in the
application for Disposal A orl s Con bructio i Permit No dated__-_.
THE ISSUANCE OF THIS CERTIFICATE. SHALL NOT OE CONSTRUED AS A GUARANTEE THAT THE
SYSTEM WILL FUNCTION SATISFACTORY.
DATF Inspector
THE COMMONWEALTH OF MASSACHUSETTS
BOARD OF HEALTH
OF
Orrtifiratr rag (!Irnnpl(ianrr
THIS TV TO CERTIFY, That the Individual Sewage Disposal System constructed ( ) or Repaired
"TV
-•■••'
NO...:.J..7.L.._.._' FF n8.PC 61 D
THE COMMONWEALTH OF MASSACHUSETTS
,BOARD OF HEALTH
6145 of22� irn
.Appliratign for Disposal cr;arks� (nunstrurtinu Drrmit
Application is hereby made for a Permit to Constru
System at:
(I')
or Repair ( ) an Individual Sewage Disposal
� tfr 1..7
) DJ� ¢�� /�� —
Ill =I.... ... ....s_ller �.wt4L.K')I i..'{ Address
" InsdOev Address
Type of Building Size Lot Sq. feet
.a Dwelling—No. of Bedrooms Expansion Attic ( ) Garbage Grinder ( )
a. Other—Type of Building No. of persons Showers ( ) — Cafeteria ( )
Other fixtures
MDesign Flow gallons per person per day. Total daily flow gallons.
C Septic Tank—Liquid capacity/eQ 5 hallons Length Width Diameter Depth
xDisposal Trench—No. Width Total Length Total leaching area (9.0.4..sq. ft.
Seepage Pit No Diameter Depth below inlet Total leaching area sq. ft.
z Other Distribution box ( ) Dosing tank ( )
Percolation Test Results Performed by Date
.7 Test Pit No. 1 minutes per inch Depth of Test Pit Depth to ground water
LT.: 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 aforedeseribed Individual Sewage Disposal System in accordance with
the provisions of Article XI of the State Sanitary Code— The undersigned further agrees not to place tile system in
operation until a Certificate of Compliance has been issued by the b rd of h • th, '/
Si: ed...• 'Y1........57.1� ,ll' �.
Application Approved By
i
Application Disapproved for the following
Dr,/. y
Date
easons'
Permit No -/.. ..t�
Issued.. c d
Dat
4.711
by
THE COMMONWEALTH OF MASSACHUSETTS
BOARD OF HEALTH
OF
Trrtifirate of aumpliunrr
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