Lot 18 Septic Applications & Plans .L IN WHERE APILICABLE
CHECK OR F
No P
THE COMMONWEALTH OF MASSACHUSETTS
BOARD OF HEALTH
C.{y OF Neri/ianlp /on
Appliratinn fur Di"pn5a1 3hnrkn Qlnn itrurtinu Perim
a
MILES J.
HUBLER
20623
Application is hereby made for a Permit to Construct (A ) or Repair ( ) an Individual Sewage
System at. pre ine'z' 1 / 9,e ^FF
esth.in/SG n fr..d
Location Addres
toGeri
Owner
Irsaller
ar Lot No.
q ieanch /4uc czsuIia�Np%a /YA0/017
Address
Address
Type of Building Size Lot 17 22C Sq. feet
Dwelling—No. of Bedroom Expansion Attic ( ) Garbage Grinder (✓) yes
Other—Type of Building No of person Showers ( ) -- Cafeteria ( )
Other fixtures
Design Flow IaT-5Th gallons per person per day. Total daily flow
Septic "Gmk-- Liquid capacity gallons Length \Fiddt
Disposal T....eb N . j1 e/4 Width /8 t Total Length /'
Seepage Pit No Diameter Depth below inlet
Dosing tank (, )
Performed by .ao
minutes per inch Depth of TVt Pit �"��
minutes per inch Depth of Te t Yi t
3
300 gallon
Diameter Depth 64a
Total leaching area._.�.�. -� sq- ft.
Total leaching area sq_ ft
Other Distribution box
Percolation Test Results
Test Pit No. 1
Test Pit No. 2
Date 5- Z•S %3
Depth to ground Ovate- n",/1C
Depth to ground water
Description of Soil_.e-25a'r kp..:LCL/ c;L 420SC
2e!`" -(c.C ' Sewd SW
least
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'
Date
Date
Permit No - Issued
Date
by
THE COMMONWEALTH OF MASSACHUSETTS
BOARD OF HEALTH
OF
Trrtifiratr of fitomplittnrr
THIS IS TO CERTIFY, That the Individual Sewage Disposal System constructed
or Repaired ( )
at
has been iti Called 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.
DAT R
Inspector
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