Lot 11 Septic Appication Permit & Plans 'HERE APPLICABLE
CHECK OR FILL IN
No .
Q.G
THE COMMONWEALTH OF MASSACHUSETTS
BOARD OF HEALTH
OF
FR,A3.:LQ0
Appliratian fur fliopunat 3llurke fontitrurtiuu Permit
Application is hereby made for a Permit to Construct
System at:
or Repair ( ) an I ndis idual Sewage Disposal
Lot or L Lot No.
faeAddress
isinlhx Addrcss
Type of Building Size Lot Sq. feet
Dwelling—No. of Bedrooms j Expansion Attic ( ) Garbage Grinder ( )
Other—Type of Building No. of patron= Showers ( ) — Cafeteria ( )
Other hx[yres
Design Flow ✓` 0 / gallons per person per dry. Dotal daily 1w gallon,.Sep tit. Tank Liquid caps ityo7 i7 g,Jlnns 1 ength_—.. .__ AVidd] Diameter Dc1utl
Disposal Trench—No With] Total Length Total leaching area b0_Qsq. ft.
Seepage Pit No Diameter Depth hel ow inlet Total cad iug area sq_ it.
Other Distribution box ( ) Dosing tank ( )
Percolation Test Results Performed by Date
Test Ht No. 1 / minutes per inch Depth of Test Pit Depth to ground water
Test Pit No. 2 minutes per inch Depth of Test Pit // Depth to ground water_
of Soil
Nature of Repairs or Alterations—..Answer when applicable
Aggreement:
The undersigned agrees to install the aforedescribed Individual Sewage Disposal System in accordance with
the provisions of Article NI of the State Sanitary _ de —The undersigned further agrees not to place the system in
operation until a Certificate of Compliance has I,•- is�t ii l�y the ba rd tealt
Sign
ey /p as
Application Approved By .. _ : '.!.' ......<.. % a. . -
Application Disapproved for the following reasons'
Permit No._6.6 6)
Issued
Date
9..1.9.Z
by
at cfrt f k", - lik 41' I';4161.-e-
Ins been installed in accordance with the provisions of Article The State Sanitary de as descJrrie pin the
application for Disposal Works Construction Permit No dntetL_ _ .. .. ..� X�_.�. THE
THE ISSUANCE OF THIS CERTIFICATE SHALL NOT BE CONSTRUED AS A GUAR TEE THAT THE
THE
SYSTEM WILL FUNCTION SATISFACTORY.
a/
DATE "A- r i..A r'I t Inspector_. . .__— 1. 4(tnt
THI
THE COMMONWEALTH OF MASSACHUSETTS
BOARD
..}�O�F �HEALTH
{„ OF / eli'l td
rrtifiratr of Tont liaurr
TI ndividual Sewage Disposal System constructed ( ) or Repaired
THE COMMONWEALTH OF MASSACHUSETTS
BOARD
_ OF HEALTH
(BI OF I/ rijrrQ n
'I
Dispnnal arks Tnnstrurtinn jrrmit
Permission is erehy granted >
to Constr chi ( t ) or Repair ( ) an In ividual Sewage Disposal System
at No s-+`
sr„, [
as shown on the application for Disposal Works Construction Permit No..6t Dated—_>(t_24_f. _12 2J..
Fea_f..i .QQ
DATE
FORM 1253 HOBBS & WARREN. I NC.. PUBLISHERS
No Fag
THE COMMONWEALTH OF MASSACHUSETTS
BOARD OF HEALTH
C/TY OF NoeTt/7grp7"o J
Applirntion for Einpoont 1:1 litho Cnonstrurtion 1rrmit
Application is hereby ma a for a Permit to Co struct ((�or Repair ( ) an Individual Sewage Disposal
System at: o1-ee/X)g.4 4
tor a//
Location-Addres
or Lot No.
Owner Address
W
In Viler Address
Type of Building Size Lot Sq. feet/
Dwelling-No. of Bedrooms , Expansion Attic ( ) Garbage Grinder (i-
a. Other—Type of Building No. of persons Showers ( ) — Cafeteria ( )
Other fixtures
Design Flow ti5.Q gallons per person per day. Total daily flow >3l.O gallons.
Ul Septic Tag_Liquid capacity.22250gallons Length.V'-O. Width_5—D_a Diameter Depth 5' 4-'
Z Disposal —No. I........ Width L.O ' Total Length.- i2' Total leaching area_S O sq. ft.
Seepage Pit No Diameter Depth below inlet Total leaching area sq. ft.
Z Other Distribution box ( ) Dosing tank ( ) _
Percolation Test Results Perform d by_.l..t%4er A'il/.GL(r-L-t; 1' SZ. Data @-fn-23
Test Pit No. 115'4'Snittigtte per inch Depth of Test Pit..0....:0 " Depth to ground water N°Ver...
Test Pit No. 2 minutes per inch Depth of Test Pit....J..rlac!(_. Depth to ground water_-A/P.ALA_...
Pe/A, rUST.-PCE6240 .../ LS2.noen _or 1Zf.EP im., .
Description of Soil L Ft " Fl{.� f....Ls-i? " .�.tL7 .5.4A�1?.�._S �0 U fAltid7
CHECK OR FI
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 folio
ing reasons•
Date
Permit No
Date
Date
Issued
Date