Lot 22 Septic Application & Permit CHECK OR PILL IN WHERE APPLICABLE
No..-@...7 / FEE./`� ' Q G
THE COMMONWEALTH OF MASSACHUSETTS
BOARD OF HEALTH
Application for fli,npooal Marko
Qlncttitrnrtinn jJrrniii
Application is hereby made forva ermit to Cons ct (V) or Repair ( ) an Indic idual Sewage Disposal
System at: 1 N I' ery ID (Li VE
OF
?)2nd`°`, �. `n
Address
or Lot N0.
Jnstan.r
Type of Building
Dwelling—No. of Bedrooms
Other—Type of Building No. of perxms
Other fixtures
n7,1„„
Size Lot Sq. feet
Expansion Attic ( ) Garbage Grinder (
Showers ( ) — Cafeteria ( )
Design Flow 6 gallons per person per day. Total d
Septic "lank—Liquid c pacitace gallons Length Width.
Disposal Trench—No. Width . Total Length
Seepage Pit No Diamete
Other Distribution box
Percolation Test Results
Test Pit No. 1
Test Pit No. 2
ly flow gallon,.
Diameter Dc}=tl'
Total leaching area CQ_ sq. ft.
Depth below inlet Total leaching are
Dosing tank ( )
Performed by -
minutes per inch Depth of "fc t Pit
ninutes per inch Depth of Test Pit
Date
Depth to ground water
Depth to ground Water_L)1 't.Q___
Description of Soil
Nature of Repairs o
er
?ns---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 Sanitar�le—The undersigned further agrees not to place the system in
operation until a Certificate of Compliance has s V ed by he boards he h.
eje6Ere - - i hkcyi l %9Zs
Application Disapproved for the following reasons'
Application Approved By
Permit No._.IG 7 / Issued -1-�A-L1..,7_s
THE COMMONWEALTH OF MASSACHUSETTS
�
/ BOARD OF HEALTH
l i fl. OF qlG��net 401
Orrtifirate of fdnmplittnrr
THIS--ttSSyyT� CE�+'T(!' Thykr t ndividual Sewage Disposal System constructed (/V.-.or Repaired ( )
at ?! sc,
has been installed in accordance with the provisions of Article XI RT f The State Sanitary Csddqe as described in the
application for Disposal Works Construction Permit No O 7/ dated JL.ZL!:. _L9.f 12i
THE ISSUANCE OF THIS CERTIFICATE SHALL NOT DE CONSTRUED AS A GUARA TEE THAT THE
SYSTEM WIIp. FUNCTION SATISFACTORY.
DATE 616 117,,r
No
Permission
to Construct
at No cJ
cif
Inspector ^'.trytGf{ !r r 67/
THE COMMONWEALTH OF MASSACHUSETTS
BOARD OF HEALTH
OF .
Di ipu ttl Wnrks Unustrurtinn permit
isafferehy granted
) or Repair ( ) an Individual SewageFDisposal System
as shown on the
Street
application for Disposal Works Construction Permit No Dated
Board of Health
DATE
FORM 1255 HOBBS & WARREN. INC.. PUBLISHERS