119 Septic Application Permit & Perc Tests s 2
No Le a
CHECK OR FILL IN WHERE APPLICABLE
THE COMMONWEALTH OF MASSACHUSETTS
BOARD OF HEALTH
,»- i ilya /7rl
OF
/' 11
Ppplirntinn fur Dismal
arks @innstrnrfinn hermit
Application is hereby made for a Permit to Construct (' ) or Repair ( ) an Individual Sewage Disposal
System at: 11
# X17 or Lot No.
Address
Installer Address
Type of Building Size Lot Sq. feet
Dwelling—No. of Bedrooms 3 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 capacity gallons ength Width Diameter pth.
Width Total Length Total leaching area... J sq. ft.
Diameter Depth below inlet Total leaching area sq. fl.
Dosing tank ( )
Performed by Date
minutes per inch Depth of Test Pit Depth to ground water
minutes per inch Depth of 'fest Pit Depth to ground water
Disposal Trench—No.
Seepage Pit No
Other Distribution box
Percolation Test Results
Test Pit No. I
Test Pit No. 2
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—Thehundersi ed further agrees not to place the system in
operation until a Certificate of Compliance has been issued b ,t e boil of jlealth.
w .1. boil
.,
"o-t - f ,l. 'S .a.a.c. tie/ire
Date
Application Approved By
Application Disapproved for the following reasons
Permit No / k (�
Date
Issued
Date
THE COMMONWEALTH OF MASSACHUSETTS
�t
BOARD /OF HEALTH�,'
dt {.k OF l/..!'7✓61-e
Militate of Qtumplianrr
THIS IS TIP CERTIFY Th the Individual Sewage Disposal System constructed (freT or Repaired ( )
by �r nz*Q4
at
.C:I
has been installed in accordance with the provisions of Article XI of The State Sanitary C as described in the
application for Disposal Works Construction Permit No )-AO dated—ai//'vd.. LLevie
THE ISSUANCE OF THIS CERTIFICATE SHALL NOT BE CONSTRUED AS A GUARANTEE THAT THE
Installer
SYSTEM W`ILL FUNCTION SATISFACTORY.
DATE i/1 ly.._LIZ Inspector.
if
No_1-L'6
044, 7' it wj(.t-la >tfn y
THE COMMONWEALTH OF MASSACHUSETTS
BOARD OF HEALTH
OF ]
Dinpnuat $' '-llurks Qlun urtiun tirrntit
Permission is reby granted �yel�"` Pe-r
FEE
to Constm t?t ,) gr Jepair (�-) an In ici 1 Sewage Disposal System
at No y- r 1
Street
as shown on the application for Disposal Works Construction 6''�'R No ll ted
tge
DATE
FORM 1255 HOBBS a WARREN. INC., PUBLISHERS
Hoard of Heal
a
ALL O t .
Soard el' :nee:;. .
City 3a1L
Nortbaetten. Mass ,
Gentlemen:
T have made sea:
ar land tationciln g to
Clement S : reet. 7
percolation ?a t• &nd 3o?i np1eai
id + 1-d;:P. o:at5`d on "__ We '.erty n .
,rCJ
For farther t . ntot on regarc.ing these teats, p eaee
the attached dke.tch „how± a the existing locations of the pe
ion tests taken and repo red to you last week, p1U6 t e ;o a + rn
of the new tests takan or.. ,eptember 28, 1965, This sketch si?cw:>
the setup for his proposed lots, plus the percolati-n, test ';ohs
an the percolation rate at eaehh hole.
e;
ce • Mr. Donald Wade
Chesterfield Ros?
Leeds , Massachusett-s
N.
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