Lot 6 Septic Appication & Permit CHECK OR FILL IN WHERE APPLICABLE
THE COMMONWEALTH OF MASSACHUSETTS
BOARD OF HEALTH
0TY- OF /�%g74/ pTor3
FEE
App iration for iilioposttl rr;'who onstrurtioa Permit
Application hereby made for a Permit to Construct (V) or Repair ( ) an Individual Sewage Disposal
System at: �iu2�
LTA CA l I I .1-
/77 p C /vs ric6, T .7tt
7
Owner
arc.
or Lot No.
Address
ta.:aner
Type of Building Size Lot 1.;5 DLZO..Sq. feet,"
Dwelling—No. of Bedrooms 3 Expansion Attic ( ) Garage Grinder (-1)
Other—Type of Building No. of persons Showers ( ) — Cafeteria ( )
Other fixtures ,3Q 0 ons.y
Design Flow D O gallons per person per dal. Total daily flow
Septic 1 Liquid capacity../. allons Length./1?-Q._. Width-5 4'' Diameter Depth _4
Disposal —No. / Width . Zq / Total Length Sc ' Total leaching area 6 O sq. ft.
Seepage Pit No Diameter Depth below inlet Total leaching area sq. ft.
Other Distribution box ( ) Dosing tank ( ) .5/ .� i 7¢
Percolation Test Results Performed by..8t l 44J) )4 JL)A.. a/ 1Sr r4YQ7ate f
Test Pit No. 1 0. 5 minutes per inch Depth of Test Pit 4'-4't Depth to ground water N'C,VC
Test Pit No. 2 minutes per inch Depth of Test Pit 7-0' Depth to ground water...No N S
8' OTS.... i Li2' CCA.YE SF/A/9._ S'— 4-e CeAti • tlNG---, .s+LA/O
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.
Signed .. ..... ..... .... ... .... ..
Application Approved By
Application Disapproved for the following reasons'
Permit No Issued
Date
Date
Date
Date
by
THE COMMONWEALTH OF MASSACHUSETTS
BOARD OF HEALTH
OF
Qtrrtifiratr of atomplittnre
THIS IS TO CERTIFY, That the Individual Sewage Disposal System constructed ( ) or Repaired ( )
I;!starer
at.
has been installed in accordance with the provisions of Article RI 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
n•rnVIl■IT••••••'..••••••11WrrO•Wern...yr••••••••••■■•••••••••••••
Z-.-•
CHECK OR FILL IN WHERE APPLICABLE
No 7a2 ....
FEE./l t C C
THE COMMONWEALTH OF MASSACHUSETTS
BOARD OF HEALTH
el) 7" _.. OF %-de/ )
Application-fns flinpunal Works ({tnnstrnrtinn lirrntit
Application is hereby made for a Permit to Construct (k) or Repair ( ) an Individual Sewage Disposal
System at:
t
(/ )14.4i._.o e LJLIff.,:(7c
u J 174
Type of Building
Dwelling—No. of Bedrooms
Other—Typ of Iiuildiug No.
Oth r fixtures
Design Flow 2 gallons p er person per da y.
Total daily flow '&O gallon-
Septic
Tank—Li annul eapacit t gallons Length Width Iiumeter-
6
or Lot No.
Address
Address
Size Lot Sq. feet
Expansion Attic ( ) Garbage Grinder ( )�
suns Showers ( ) -- Cafeteria ( )
Disposal Trench— No.
Seepage Pit No
Other Distribution box ( )
Percolation Test Results
Test Pit No. 1
Test Pit No. 2
Description of Soil.
Dcialt.
6.1! 1 Total Length j! ! Total leaching area &G-li sq. ft.
Diameter Depth below inlet Total lead g are sq. IT
Dosing tank ( )
Performed by Date
z Depth ground water
minutes per bah Depth of Test Pit De tlt to
minutes per inch Depth of Test Pi Depth to ground wa[c-/12 CA<_.-
Nature of Repairs or Alterations--An r when applicable
Agreement:
The undersigned agrees to install the aforedescrihed Individual Sewage Disposal System in accordance with
the provisions of Article NI 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 ealth
Signed _ ...Y_ ,,..
V n7aa
Application Disapproved for the following reasons' l -
Application Approved By
o
Permit No 7,1/ Issued
Date
by
THE COMMONWEALTH OF MASSACHUSETTS
BOARD OF HEALTH
OF _.. .
Trrtifiratr of Cnmptianrr
THIS IS TO CERTIFY, That the Individual Sewage Disposal System constructed ( ) or Repaired
at
has been installed in accordance with the provisions of Article NI 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 Inspector