Lot 16 Septic Applications Permits & Plans No 73 % Fsa..Ls' 0 4
THE COMMONWEALTH OF MASSACHUSETTS
BOARD OF HEALTH
ems% - OF g eri-2a
1ppliratiun for 3ispoottl iflurto (Ilunutrnrtiun Penult
Application is hereby'made for a Permit to Construct (k ) or Repair ( ) an Individual Sewage Disposal
System at:
l/n1s+'cr'a-
or Ito: Na
Address
u Add,ors
pe of Building 99 Size Lot. Sq. feet
Dwelling—No. of B drooms__-3 Fepansion Attic ( ) Garbage Grinder (/��
Other— Type of Building No. of persists Showers ( ) — Cafeteria ( )
Other fixtur,s —
Design Flow S D gallmn, per p :wn per day. Total daily flow 300 gallon-.
Se t c itmk—I rgmd cap leityligp.e.gblIons Length VA'idth Drtmetcr _ D h
Disposal Trench—No AA bid, -__ .Tonal I eagh...3U "Total leaching : -...61,-Q --rq. in.
Seepage Pit No Diameter Depth below inlet Total leaching
Other Distribution hex ( ) Dosing tank ( )
Percolation Test Results Pe firmed by.. y I)ate
Test Pit No. 1- ..3 minutes per inch Depth of Test t Pit �! Depth to . and vcatr-77i-e7C_ ...
Test Pit No. 2 minutes per inch Depth of Test Pit Depth to ground w:[IC.__.
Description of Soil
Nature of Repairs or Alter ins—Answer when applicable
Agreement:
The undersigned agrees to install the aforedesc:ibed Individual Sewage Disposal System in accordance v.io.
the provisions of Article NI of the State Sanirary Code—The.undersigna 1 further agrees not to place the system iu
operation until a Certificate of Compliance has been issued by the board of health.
Il
Signed
Application Approved By -I' _. "r ""'n
Application Disapproved for the following reasons'
Permit No._-{3 if Issued
by
THE COMMONWEALTH OF MASSACHUSETTS
BOARD OF HEALTH
OF
Trrtifiratr of flontplittnrr
THIS IS TO CERTIFY, That the Individual Sewage Disposal System constructed ( 1 or Repaired (
Instarer
at
Iris peen installed in r:ccor<kance with the provision, of .Article XI of The State S:niitarr. 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.
ATP Inspector
by
THE COMMONWEALTH OF MASSACHUSETTS
BOARD OF HEALTH
OF
alrrtifiratr of QQamplianrr
THIS IS TO CERTIFY, That the Individual Sewage Disposal System constructed ( ) or Repaired
at
has been installed in accordance with the provisions of Article XI 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.
D ATF Inspector
No
THE COMMONWEALTH OF MASSACHUSETTS
BOARD OF HEALTH
( (��y..i.. OF %%!'-Y_del.aJI.p1..Cr1.
1 1
fli,poottl Works Tnnstrurtiou '/rrmit
Permission is hereby granted_.___.._._:_4_2, r'
to Construct (k"") or Repair ( ) an Individual Sewage Disposal System
at No
FEEL�:Z.4.e
strut
as shown on the application for Disposal Works Construction Permit No ,/_` i Dated Et
DATE
FORM 1255 HOBBS & WARREN. INC.. PUBLISHERS
/ ..,., ft A
Board of Health
..... 4
LL IN WHERE APPLICABLE
CHECK OR
No
THE COMMONWEALTH OF MASSACHUSETTS
BOARD OF HEALTH
ray OF_NC/ Mampfcn
Appliratinu far Ditw nal niurkn Cnnuntrurtinn lrrmit
Application is hereby made for a Permit to Construct (x ) or Repair ( ) an LIE idual Sewage Disposal
System at:P' tF /%Eft -Len, / Gn e �C<
L Canon AGar v
!eater .0 hf.,iL..tJ
*16
or Lot so.
Owner Address
Installer Address
Type of Building Size lot 45: -572- Sq. feej
Dwelling—No. of Bedrooms 3 Expansion Attic ( ) Garbage Grinder ( ) yCS
Other—Type of Building No. of pe who Showers ( ) — Cafeteria ( )
Other fixtures
Design Flow Sc Jam gallons per person per day. Total daily now 30Ce gallon
Septic Tank—Liquid capacity/ere..gallons Length Width Diameter Depth b,a6_.
Disposal T-each— A EALLi Width JJ Total Length a/ Total leaching rtrc:i__3t sq. ft.
Seepage Pit No Diameter Depth below inlet Total leaching area sq- ft.
Other Distribution box ( ) Dosing Mk )
Percolation Test Results Performed by A.0.4 , /T -et/l- iE Date 6'- 2 S— 7 3
Test Pit No. I 3-111i1111tc per inch Depth of vt Pit 7C' Depth to ground water_.PcnC
Test Pit No. 2 minutes per inch Depth of Test Pit Depth to ground water
Description of Soil /-90 se; ( h.$ 6 een rCM cYed O '-4 ' as'fFy sand S?!2_
lcose/ 6" - 7e' Silt)..d..__?'14'_ln-Qse Ste ire 9rnve-/
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 fort]'Cr 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
Trrtifiratr at (iinm}Tlitturr
THIS IS TO CERTIFY, That the Individual Sewage Disposal System constructed ( ) or Repaired ( )
at
has heen installed in accordance with the provisions of Article XI 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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