Lot 12 Septic Appication & Permit CHECK OR FILL IN WHERE APPLICABLE
No...�,r_,C..F
FE], /ST OQ
THE COMMONWEALTH OF MASSACHUSETTS
BOARD OF HEALTH
OF
Appliratinn for flinpnsal 3 nrltn
Application is hereby made for a Permit to Construct
System at:
ntmtrnrtinn lJrrntit
or Repair ( ) an India iduul Sewage Disposal
,.nergtLKS,c g
Installer
Type of Building
Dwelling—No. of Bedroom=
Other—Type of Building No. of persons
Other fixtures
or c.or No.
Address
dLtiresz
Size Lot Sq. fee. t /
cpansion Attic ( ) Garbage Grinder (H'
Showers ( ) — Cafeteria ( )
Design Flow eiallons per
Septic ink Liquid capacit h 6T gallons I
Disposal Trench No Width
Seepage Pit No Diameter
Other Distribution box ( ) Dosing tank ( )
Percolation Test Results Performed by
Test Pit No. I / minutes per inch
Test Pit No. 2 nuinntes per inch
person n per day. Total daily low gallon.
ath VVidth Diameter Depth
Total Length Total leaching area sq. ft.
Depth below inlet Total leaching are', sq- ft.
Date
Depth of Test Pit .-..- .. Depth to ground water -
Depth of Test ryry Pit 7/ b Depth to ground water-./IZ_P_11.4
Description of Soil
Nature of Repairs or Alterations—Answer when applicable
Agreement:
The undersigned agrees to install the afaredescrihed Individual Sewage Disposal System in accordance with
the provisions of Article NI of the State Sanitar ale—The undersigned further agrees not to place the system in
operation until a Certificate of Compliance has ern iss1-d b the boar of he Ith. �. .
Application Approved By
Application Disapproved for the following
d
nn U�9 /973—
nare
ensons•
Permit No 6 E /
at
has been ins ailed in accordance with the provisions of Articl�j X!r The State Sanitary de as described in he_
application for Disposal Works Construction Permit No (�t_C.. dated . — 7J
THE ISSUANCE OF THIS CERTIFICATE SHALL NOT BE CONSTRUED AS A GUAR TEE THAT THE
SYSTEM WI FUNCTION SATpISJFACTORY.
DATF oC O dt_�../../_.S Inspector 4.
THE COMMONWEALTH OF MASSACHUSETTS
BOARD OF HEALTH
(j44, OF /451°4461n7Lefinl
'@irrtifiratr of (llampliaurr
Tai CFray at Individual Sewage Disposal System constructed ( " ) or Repaired ( )
' /� (
nstniteo
p : 1?0
No
THE COMMONWEALTH COMMONWEALTH OF MASSACHUSETTS
BOARD OF HEALTH
ti
r.. OF
•
FEE 2
is}Ta�al-3 nrka C4anstrurt on lrrmit
Permission is,hereby granted
or Repair ( )-an Individual Sewage Diwsal System
I .
to Construct
at No
as shown on the
St e
application for Disposal Works Construction Permit No Dated
DATE
FORM 1255 HOBBS & WARREN. INC
PUBLISHERS
Board of PERINI