Lot 14 Septic Appications 'HERE APPLICABLE
CHECK OR FILL IN
No 73°1—
THE COMMONWEALTH OF MASSACHUSETTS
BOARD OF HEALTH
OF
Application -fit Qhip Dal ilfnrkn`tnnntitrurtiun Prrmit
Application is hereby made for a Permit to Construct (i<or Repair ( ) an Indiridua) Sewage Disposal
System at:
dA or Loa No.
Address
Address
Type of Building " Size Lot Sq. feet
No. of Bedrooms 3 Expansion Attic ( ) Garbage Grinder (sue
Other—Type of Building No of persons Showers ( ) — Cafeteria ( )
Other fis[nres
Design Flow 50 gallons per person per day Total daily low 3D0 gallon-
Septic Tank— Liquid pacitk20Q gallons Length Width Uinmcter Dept'
Disposal Trench—No. \Vidth. AO Total Length U Total leaching area fi_o
sg. tt.
Seepage Pit No Diameter Depth below inlet Total leadiing area sg. it.
Dosing tank ( )
Performed by ... -/-_-_-7 Date
minutes per inch Depth of Test Pita( 1 6 Depth to ground water
minutes per inch Depth of Test Pit- r i re Depth to ground watee440 1X,
Other Distribution box ( )
Percolation Test f esulttp-
Test Pit No. l..t . .. _
Test Pit No. 2
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 AI of the State Sanitary Code—The undersigned further agrees not to place the system in
operation until a Certificate of Compliance ha' been issued by the boar of health.
DoE
Application Disapproved for the following reasons -
Application Approved By
Permit No._73;Z-
Issued
/ ill(
Dare
by
THE COMMONWEALTH OF MASSACHUSETTS
BOARD OF HEALTH
OF
tnrrtifiratr of (IIumpttaurr
THIS IS TO CERTIFY, That the Individual Sewage Disposal System constructed ( ) or Repaired ( )
In tuMcr
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.
DATE Inspector
CHECK OR FILL IN WHERE APPLICABLE
No FEE-
THE COMMONWEALTH OF MASSACHUSETTS
BOARD OF HEALTH
GiTY OF /e-%02TN.Wnare
Application for Disposal ri,nrks Olnnstrurtinn permit
Application is hereb made for a Permit to Construct (t-) or Repair ( ) an Individual Sewage Disposal
System at: -ayo i
Location Address or Lot No.
Owner
Address
Installer Address
Type of Building Size Lot Sq. feet/
Dwelling—No. of Bedrooms S Expansion Attic ( ) Garbage Grinder (✓f
Other—Type of Building No. of persons Showers ( ) — Cafeteria ( )
Other fixtures
Design Flow - gallons per person�er day. Total daily flow ....30.0 talons.
Septic Ta Liquid capacity�0 gallons Length/ .J Widtha._=ea Diameter D`epth. 1-4..”-4.a
Disposal No. /......_.. Width Z Q s Total Length .30 ' Total leaching area.._.O W sq. ft.
Seepage Pit No Diameter Depth below inlet Total leaching area sq. ft.
Other Distribution box ( ) Dosing tank ( )
G tr-Percolation Test Results Performed by..sd k f.t t.kg1 M T al Date B . - 7-3
Test Pit No. 1.0e6 %minutes per inch Depth of Test Pit... —y�.nDepth to ground water...410/.!%C-.
Test Pit No. 2 minutes per inch Depth of Test Pit..6 1 b a Depth to ground water._AZIL..t...
Description of Soil 3 'f ZW.4'%/Y,e..y /C.3 i/SL(.! f 54lMo, -> (r.24 5/94/0
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'
Permit No
Date
Data
Data
Issued
D