Lot 20 Septic Applications & Permits CHECK OR FILL IN WHERE APPLICABLE
Fart
THE COMMONWEALTH OF MASSACHUSETTS
BOARD OF HEALTH
er /yip 70 Al
Application for Disposal Wnrksyftnnntrnrtinn trmit
lion is hereby made for a Permit to Construct ( or Repair ( ) an Individual
Sewage age Disposal
System O a�t:
11?40L_._C'� Zcf)CT/ON, /NL or Lot No.
...... ... .VSe
Owner mare:.
mn:aner ^�
Type of Building Size Lot 15IJ�.9 / Sq. feet__
Dwelling—No. of Bedrooms 3 Expansion Attic ( ) Garbage Grinder (---)
Other—Type of Building No. of persons Showers ( ) — Cafeteria ( )
Other fixtures
Design Flow S0 gallons per person per day. Total daily flow -.0?.Q gallons.
Septic Tar-Ligmd capa<ityLlflP...gallons Length./0-a°�Vidth..5-0 ' Diameter Depth_S 1-4-1
Disposal Tseo'�lt—No / Width T@ 1 Total Length 5O e Total leaching area....(0t".d...sq. ft.
Seepage Pit No Diameter Depth below inlet Total leaching area sq. ft.
Other Distribution box ( ) Dosing tank ( )
Percolation Test Results Performed byt tLMQ/%54a,V 'i.a///Z?rat Date 5,12,e2/24-
Test Pit No. 1 /' 0 minutes per inch Depth of Test Pit 4 ii '1. Depth to ground water 4/o4/r
Test Pit No. 2 minutes per inch Depth of Test Pit 7 0 .'Depth to ground water it/°''V r
I
Descrriiotion of Soil 3' QTS I i '—O v 5/cJ f.3/-0"---- 44-1 q F (j ck y Z! 9 ,a
e.19 —54462
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
Date
Permit No Issued
Date
by
THE COMMONWEALTH OF MASSACHUSETTS
BOARD OF HEALTH
OF
Tut-direr of Qinmplianre
THIS IS TO CERTIFY, That the Individual Sewage Disposal System constructed ( ) or Repaired
is starer
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.
DATE Inspector
No...73.(
THE COMMONWEALTH OF MASSACHUSETTS
FEE.-.S.Q_a....
BOARD OF HEALTH
1
Appliration for Oiu}tuial illurks Lutuitrurtitta Permit
Application is hereby'made for a Permit to Construct (V) or Repair ( ) an Indic idual Sewage Disposal
System at:
qqqq/��^�y������.-� N 016
<l :1L t- or Lot Na.
Type of Building
Dwelling--No. of Be lmmns_-3
Other Type of Buil ling
Other iisturc
Design Flow
Septic T' d — Liquid capa
Disposal Conch No
Seepage Pit No
Other Distribution box ( )
Percolation Test Results
Test Pit No. i ./.c1)
Test Pit No. 2
Size Lot Sq. feet
-man on Attic ( ) Garbage Grinder (1<
No. of person: Showers ( ) — Cafeteria ( )
gallons per person per clay. Total daily flow Sid_. gallon-
it /aft-*allons Length Width Di-meter IJ I r _-
Width—alQ Total Length 10 Total leaching aron_44 sq. ft
Diameter - Depth below inlet Total Icidtiug area rq. I:
Dosing tank ( )
Performed by Date
minutes per inch Depth of Test 1'it if Depth to ground weter
nunu es per inch Depth of Test Nit 7' Depth to ground cr _. ._-
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 NI 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.
Sign _ C'_. '�_ _ u4..k' 9 y p
ALtr"12)_/.7-7,‘
Application Approved By
e.
Application Disapproved for the following reasons'
Permit No._7 3 7 Issued
Ffj 11.9
by
THE COMMONWEALTH OF MASSACHUSETTS
BOARD OF HEALTH
OF
Trrtifiratr of (duutplianrr
THIS IS TO CERTIFY. That the Individual Sewage Disposal System constructed ( 1 or Reoafred ( )
I a been in;'alle l in accordance with the provisions cif Article NC of The State Sanitary Code as dosufhed in the
application for Disposal Works Construcien Permit No dated
THE ISSUANCE OF THIS CERTIFICATE SHALL NOT BE CONSTRUED AS A GUARANTEE THAT THE
SYSTEM WILL FUNCTION SATISFACTORY.
DATE Inspector
by
THE COMMONWEALTH OF MASSACHUSETTS
BOARD OF HEALTH
OF
Qtrrtifiratr of Qlantplianrr
THIS IS TO CERTIFY, That the Individual Sewage Disposal System constructed ( ) or Repaired
)
Installer
at -
llns 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.
DATE Inspector
No 12: 7
THE COMMONWEALTH OF MASSACHUSETTS
BOARD OF HEALTH�f+--
1( 1 � OF t/}i°.S(%as! i41':SS'_l1-
Pl0000a1 Iflorlia Qinnitrurtiou Permit
FEE j. ,..1"
Permission is ereby granted '- }-!
to Construct ( ) or Repair ( ) an Individual Se age Disposal System
at No —f 1 iJ _. .�'.... ^ 4- ii.t --'t-.•
sla.<
as shown on the application for Disposal Workl Construction Permit Na / Dated yet h_4'
DATF
FORM 1255 HOBBS & 'NAPS EN. INC.. PUBLISHERS