Lot 23 Septic Applications & Permit No. .
CHECK OR FILL IN WHERE APPLICABLE
THE COMMONWEALTH OF MASSACHUSETTS
BOARD OF HEALTH
C. ry OF . O TF/H/n PTO A/
FEE
Ap liratiun for flispnsal rr;orks QInttsirurtiott hermit
Application is hereby made for a Permit to Construct (L/jor Repair ( ) an Individual Sewage Disposal
System aat:,t ��q/ �[�///�
4'a' / icaf• 23
4RDi Cem j11=1/it/ /A c- I . aye.
Owner Address
Installer Address 23;754- 5 Sq. feet,-
Type of Building Size Lot
Dwelling—No. of Bedrooms sa Expansion Attic ( ) Garbage Grinder (✓)
Other—Type of Building No. of persons Showers ( ) — Cafeteria ( )
Other fixtures
Design Flow ,.SD gallons per person per day. Total daily flow 300 gallons.
Septic Ta�fquid capacity 1290 gallons Length.l.Q'-0' Width fL,c 'l Diameter Depth..21' L 4�
Disposal No t Width ZQ l Total Length ..30 r Total leaching area 6200 sq. ft.
Seepage Pit No Diameter Depth below inlet Total leaching area sq. ft.
Other Distribution box ( ) Dosing ( )
Percolation Test Results. Performed by.ffii zeocDe 59B/A1-t11i/Nr4"v Date ,5/Zei74
Test Pit No. 1.%� s� 0�
minutes per inch Depth of Test Pit_.....�..� Depth to ground water
Test Pit No. 2 minutes per inch Depth of Test Pit 7—e' " Depth to ground water -.—.3 's
Description of Soil 1:0 1' APE-4/7 5 i! a- 6 -
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
THE COMMONWEALTH OF MASSACHUSETTS
BOARD )OF HEALTH
OF ){Qf�.fn�t�?X1
erTifirttte of (llnm littnrr
THIS- --0 CEPT[F-Y, That thF Jndividual Sewage Disposal System constructed ( f) or Repaired ( )
by .. ,I. : . a
�f �� t �� �
at �l 3...JQ,./44k 1i m(Y
has been installed in accordance with the provisions of Article . I 7of The State Sanitary Code as described in the
application for Disposal Works Construction Permit mit No -f--a dated `'y'',,`,jj' 9, I-%4.5.
THE ISSUANCE OF THIS CERTIFICATE SHALL NOT BE CONSTRUED AS A GUARANTEE THAT THE
SYSTEM WILLYFUNCTION SATISFACTORY.
DATE
aito, 1175
Inspector t 1 ei'r+m-ti
THE COMMONWEALTH OF MASSACHUSETTS
BOARD OF HEALTH
OF r
No
Bin{Tn0tt1 Works Cnnnstrurtinn Permit
Permission is hereby granted +' Q.W.tes-71'E
to Construct ( ) or Repair ( ) an Individual Sewage Disposal System
at No j
Stoat
as shown on the application for Disposal Works Construction Permit No Dated
FEE
Health
DATE
FORM 1255 HOBBS & WARREN. INC. PUBLISHERS