Lot 10 Septic Appication Permit & Plans ERE APPLICABLE
CHECK OR FILL IN
No..�alt2
THE COMMONWEALTH OF MASSACHUSETTS
FEx/3- 6
BOARD OF HEALTH
� .. . OF , lii13ti
.Applirutinn -for fli,n#Innnl Mario (nnnstrurtinn lrrutit
Application is hereby made for a Permit to Construct ( ) or Repair ( ) an ludic idmtl Sewage Disposal
System at:
iitc2lebcco -AC- -417d
o.n
o- t __
or In No.
eil
degAadarr
Installer
Type of Building
Dwelling— No. of Bedrooms
Other—Type of Building
Outer tismres
Design Flow
Address
Size Lot Sq. feet
Expansion Attic ( ) Garbage Grinder (L No. of persons Showers ( ) — Cafeteria ( )
-.5-_4 :dlons per person per day Total daily flow .3Q 0 gallon..
Srfc 'I:utk—Liquid cajacitriatsgdlons Length Width Diameter De]],.■l
Disposal Trench—No Width Total Length Total leaching area /O.QO_sq. h.
Seepage Pit No Diameter Depth below inlet Total leaching area sq. tt.
Other Distribution box ( ) Dosing tank ( )
Percolation Test Resultss Performed by Date
Test l'it No. 1_..c . minutes per inch Depth of Test Pit Depth to ground rvate
Test Pit No. 2 minutes per inch Depth of Test Pit 7� Depth to ground water_/JZ_011A_.
Description of Soil
Nature of Repairs or Alterations—Answer 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 • e The nndersiiupuued further agrees not to place the system in
operation until a Certificate of Compliance has --n .t b fd -
r
Signed.__ji
Application Approved By
Pla 1,, '
Application Disapproved for the following reasons'
/p7-
f
nett
� 5 Permit No_..(ll.�
Issued
Aetit ate/9 /973
(M
THE COMMONWEALTH OF MASSACHUSEITS
', BOARD OF HEALTH
A
) 1
Trrlifiralr of (itnmpltante
THI$7ST LEIILTITT,Tfat. he ludividual Sewage Disposal System constructed (Le< Repaired (
by
at
has hem installed in accordance with the provisions of Article I of The State Sanitary Co x de as described in 4he
application for Disposal Works Construction Permit No 1.��..
THE ISSUANCE OF THIS CERTIFICATE SHALL NOT BE CONSTRUED AS A GUARATEE THAT THE
SYSTEM WILL FUNCTION SATISFACTORY. rm. .
DATE :: ;,t 0711, 177, Inspector G3';
THE COMMONWEALTH OF MASSACHUSETTS
BOARD OF HEALTH
OF
No FEE
Dinpnnal Marko Q•nunlrurtinn Wroth
Permission is hereby granted
to Construct ( ) or Repair ( ) an Individual Sewage Disp4a1 System
at No
Strca
as shown on the application for Disposal Works Construction Permit No Dated
Boa rd of 11 ca1111
DATE
FORM 1255 HOBBS & WARREN INC.. PUBLISHERS
+3
CHECK OR FILL IN WHERE
No
THE COMMONWEALTH OF MASSACHUSETTS
BOARD OF HEALTH
et7y OF Nor_flzam,c-/en
Apptiratintt fur fitt}Tnnal 3finrkn UTAttitrttrtintt Perini
F
Application is hereby made for a Permit to Construct ( r) or Repair ( ) an Indio idual Sewage Disposal
System at• P'°& 1YJ✓»./e'c / t•O2 .'i
Wes a»i1 Atn P9 AA .l�,.ec.K + 1 D
1 )eraa.nddress O
or Lot No.
ache•/ J. 2gaJI .n .9._ranch....Ace, 5asibana cr.I.Address !NA01ezq
Owner
Installer Address
Type of Building Size Lot. /S.6 Z,$_ Sq. feet
Dwelling-No. of Bedrooms 3 -.Expansion Attic ( ) Garbage Grinder (V)yeS
Other—Type of Building _ No of persons. Showers ( ) -- Cafeteria ( )
Other fixtures
Design Flow St J5 gallons per person per day. Total daily flow 3c.o gallons
Septic "Came—Liquid capaa(t 'g:dlons Length Width Diameter Dept 1' ase
Disposal T,....lp N>._atid. Width 18 c Total Length e2/1 Total leaching area--. -tftl sq. ft.
Seepage Fit No Diameter Depth below inlet Total leaching area sq. t:
Other Distribution box ( ) Dosing tank ( )
Percolation Test Results
P
minutes per inch Depth of Test Pit Depth to ground water
Dosing yyyytt p
Performed by Jt-/4 a_tL:u.. ..... .v_f'G.__.. Date s—ZS-73
Routes per inch Depth of est 1'it ?zCr Depth to ground
Test Pit No. I
Test Pit No. 2
Description of Soil
i&csei- _/8"- %of san4 W' locs-
rarer lt0fC
o-6° Ice sc/ ( G,-L letsr.,.__E '• -/8 ° s:1fy sew id _SM
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 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 health.
Signed
Application Approved By
Application Disapproved for the following reasons'
Date
Date
Date
Permit No Issued
Date
by
THE COMMONWEALTH OF MASSACHUSETTS
BOARD OF HEALTH
OF
htrrtifiratr of Qlnnt}Tlianrr
THIS 1S TO CERTIFY, That the Individual Sewage Disposal System constructed ( ) o
Repaired ( )
Installer
at
homes been installed in accordance with the provisions of Article X1 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
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