Lot 5 Septic Appication & Permit No Fee
THE COMMONWEALTH OF MASSACHUSETTS
BOARD OF HEALTH
r. r.7' of . /V QCT/IRmo7+t✓
W`"' )lppiiratinn for iDinpanal rinrkn Cinnntrnrtina ermif
Applicati hereby ma a for a P mit to Construct (t�) or Repair ( ) an Individual Sewage Disposal
System at: -�t�/Cf %I<Coins
NL /,/LD
�y/ Location•Addres or Lot No.
....L.:!.i1'F/O/ G Nst c zc 22.0&4 /N
Owner Address
CHECK OR FILL IN WHERE APPLICABLE
+teS
Installer .v nrrs
Type of Building Size Lot_.LS,.(2 C?b...Sq. feet
Dwelling—No. of Bedrooms •s 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 a Cr 0 gallons.
Septic Tank,,— capacity /t't>C gallons Length /4 -B a Width 5-0" Diameter DepthS i�°
Disposal iTetras—No. / Width Z4?.' Total Length 3C t Total leaching area. .42(7 O sq. ft.
Seepage Pit No Diameter Depth below inlet Total leaching area sq. ft.
Other Distribution box ( ) Dosing tank ( ) .
Percolation Test Results Performed by.kr. itede Si_'.Q.f.Q&/' '-den t£.1..51.14Date..-5/247..791
Test Pit No. I t• 53 linutes per inch Depth of Test Pit 4'-G a Depth to ground water 112.tell ..
Test Pit No. 2 minutes per inch Depth of Test Pit 61"Co t Depth to ground water 6 LG '
Description of Soil (5° O7) ,-./ L Cv h COA.€SF -5.4,14)t 4-/--4 t !.=/A/.6 ....44/0
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
Application Approved By
Application Disapproved for the following reasons•
Date
Data
Date
Permit No Issued
Date
b
THE COMMONWEALTH OF MASSACHUSETTS
BOARD OF HEALTH
OF . . . . . . . . . ..... . . .. .
fbertifiratr of ftContplianre
THIS IS TO CERTIFY, That the Individual Sewage Disposal System constructed ( ) or Repaired
Install&
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 1
THE COMMONWEALTH OF MASSACHUSETTS
BOARD OF HEALTH
(L ?14 OF :/c- (tap
)Il r,
Appliration for Utapo,nal Mork!' &instruction Urrnttt
s, ( C
Application is hereby made for a Permit to Construct (I ) or Repair ( ) an lndi‘idual Sewage Disposal
System at:
"Li-4 it t-s.
ti11-aretw`4. (�.EYrcciaCl
0
or).at No.
Add
Address
Type of Building`' �.�.��.�. -, Size Lot Sq. feet
Dwelling—No. of Bedrooms -? Expansion Attic ( ) Garbage Grinder ( 2
Other—Type of Building No. of person; Showers ( ) — Cafeteria ( )
Other tistures _
Design Flow ..;D..e gallons per person per day. Total daily flow [C gallon*.
Septic Tank--ik Liquid c:tpacitSk g:dlons Length Width Diameter Depth
Disposal Trench No Width GI Total Length •/ Total leaching area__ECE sq. ft.
Seepage Pit No Diameter Depth below inlet Total leaching are sq. t:.
Other Distribution box ( ) Dosing tank ( )
Percolation Test Results Performed by - Date -
Test Pit No. 1.1,33 rvinutes per inch Depth of Test Pity'et Depth to ground water
Test Pit No. 2 minutes per inch Depth of Test Pit Err Depth to ground water
Description of Soil -
Nature of Repairs or Al terations—Answer when applicable
Agreement:
The undersigned agrees to install the aforedescrihed Individual Sewage Disposal System in accordance with
the provisions of Article Nl 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 ... rAt 9 T �_n
lel Application Approved By Yj�,}fLt.. --I L/..:- • k; ` i"i -P-t Dal 1��--�4
U lllll� Date
Application Disapproved for the following reasons'
Permit No.._7+ k"'
Issued.
[/2
Date
IL,J f /Date
Date
by
THE COMMONWEALTH OF MASSACHUSETTS
BOARD OF HEALTH
OF
&rtifitatr of (dompliante
THIS IS TO CERTIFY, That the Individual Sewage Disposal System constructed ( ) or Repaired
mnaaer
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.
DATF
Inspecto