830 Septic Applications W
d Type of Building
U
Dwelling---No. of Bedrooms
No
Application
THE COMMONWEALTH OF MASSACHUSETTS
BOARD OFU�{.,�.•EALTH
OF
Fee
nr 33inpnnal i lnrkn Construction lrrmit
Application is hereby made for a Permit to Construct (X) or Repair
ovmuer
an Inditidual Sewage Disposal
"I. Other—Type of Building
a■ Other fixtures
Address p
Size Lot_p 4t 4 Sq. feet
Expansion Attic ( ) Garbage Grinder ( )
No. of persons Showers ( ) — Cafeteria ( )
• Design Flow
• Septic Tank—Liquid capacity gallons
e7 Disposal Trench--No. Width
allons per person per day. Total daily flow gallons.
Length Width Diameter Depth
Total Length Total leaching area sq. ft.
pth belpw it et 'Iota) leaching area sq. ft.
• Seepage Pit No Diameter _
z Other Distribution box ( ) Do. ng 4� ( )
Percolation Test Results Performed b . . �,(
1-410--'
.-1 Test Pit No. 1 minutes per inch I epth of Tesf Pit
Test Pit No. 2 minutes per inch Depth of Test Pit
NW ' Date % L f 19 7
S367° th to ground wat „n ecnl2_....
O Description of Soil. ti..-.ret-A.?b-e.
▪ U .c�,_�.�:P,.s... -ty, '7 A.R tell,, ..
Depth to ground water
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 by the board of health.
Signed
Date
Date
Date
Permit No Issued
Application Approved By
Application Disapproved for the following reaso
Date
THE COMMONWEALTH OF MASSACHUSETTS
CHECK OR FILL IN WHERE APPLICABLE
91 .No...... ._ FEB Fua.
THE COMMONWEALTH OF MASSACHUSETTS
,t . $$-BOARD OF HEALTH
OF �?ry.(�rPn
Appliratinn fur 3inpnnnl works Ulnnntrurtinn lrrmit
Application is hereby made for a Permit to Construct (V)--or Repair
Installer
Type of Building
Dwelling—No. of Bedrooms
Other—Type of Building No. of persons
Other fixtures
Design Flow _J,Q-n gallons per person per day. Total daily
Septic Tank—Liquid capacity/nkfgallons Length Width
Disposal Trench—No Width..old t Total Length._._S✓
Seepage Pit No Diameter Depth below inlet
Other Distribution box (X) Dosing tank ( )
Percolation Test Results i Performed by
Test Pit No. 1 ..5 minutes per inch
Test Pit No. 2 minutes per inch
an Individual Sewage Disposal
or Lot No.
Address
Address
Size Lot Sq. feet
Expansion Attic ( ) Garbage Grinder ( )
Showers ( ) - Cafeteria ( )
flow 59 0 gallons.
Diameter Depth
Total leaching area. //1.d...Q..sq. ft.
Total leaching area sq. ft.
Date
Depth of Test Pit Depth to ground water
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 by the board of health.
d;
Application Approved By 2/t C 't�iLLD /y?/
Date
Application Disapproved for the following reasons'