17 Septic Application Permit & Plans ERE APPLICABLE
0
0
No
THE COMMONWEALTH OF MASSACHUSETTS
BOARD OF HEALTH
c sit OF /Or 1/7CiAn/p.kV?
Appliratinu for Qiipnnal Marko Lnnotrortinn lirrmtt
N\MILES R
•
-
20623 Iaf
CtS1EF W,
Application is hereby made for a Permit to Construct (A) or Repair ( ) an lndh idual Sewage Disposal
System at: pine l,7' d»t ' /I'n'` i•
Lal,t�on-Aama,
ffoAcrf- -r Na.tL�tf
Owner
Installer
.164 "/7
or Lm No.
cJ rant/? Ave desf/ a.npiil M4
Addrrsr 0/017
Type of Building
Dwelling—No. of Bedrooms 3 Expansion
Other—Type of Building No of persons
Other fixtures ..
Design Plow 3. J2- gallons per person per day.
Septic Ltik Liquid caaarih.krelrgallons Length A1.
Disposal e ict width 18 ' Total Length 2 f'
Seepage Pit No Diameter Depth below inlet
Other Distribution box ( ) Dosing to kk (. )
Percolation Test Results Performed by /dJ- -
p
Test Pit No. 1 a. minutes per inch Depth of Te. Pat &p&
Test Pit No. 2 minutes per inch Depth of Test Pit
Address
Size Lot /7..903 Sq. feet
tic ( ) Garbage Grinder (V) y4S
Showers ( ) — Cafeteria ( )
lm ___.__3c<
1 :nctc
Total leaching area
Total leaching arc:
gallons
De al 6;42.
Sn_sq. ft
sl- 0
atE Date $ 2S`- 13
Depth to ground water-__LI ...el C
Depth to ground water
Description of Soil O -F " fop sal/ OL /era; "—/8 s./fy sa,a4 SA2 /cc'la sand W /case seme travel.
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.
Signed
Application Approved By
Application Disapproved for the follou»to reasons'
Date
Date
Permit No. Issued
Dam
by
THE COMMONWEALTH OF MASSACHUSETTS
BOARD OF HEALTH
OF
«trrtifiratr of hinmplianrr
TIIIS IS TO CERTIFY, That the Individual Sewage Disposal System constructed ( ) or Repaired
Ina.,uer
at
by heel, iustdled in accordLuse 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
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CHECK OR FILL IN WHERE APPLICABLE
No I—%—{
THE COMMONWEALTH OF MASSACHUSETTS
BOARD OF HEALTH
OF ie' _ tit-4740' .rd
Appliratiun tor +Jiipnotti illnrks tonotrurtinn lrrntii
Fxu
Application is hereby"made for a Permit to Construct ( freci Repair ( ) an 1ndis idual Sewage Disposal
System at:
Type of Building
Dwelling—No. of Bedrooms Expansion Attic
Other—Type of Building No of persons
Other fixtures
f /
_:4oAat._ALl:LrC
9oa1
y}tyj"--c it 1
.4..1±1 I .1/::i1�A
t / 7
or Lot No.
Address
Address
Size Lot Sq. feet
Garbage Grinder (
Showers ( ) -- Cafeteria ( )
Design Flow �:._(L-- .gallons per person per day. Total daily
Septic Tunic—Liquid capacitvI- La..grIlons Length Width
Disposal Trench—No._—_. ._— \Vidtit_L.'___.Total Length =v,
Seepage Pit No Diameter Depth below inlet
Other Distribution box ( ) Dosing tank ( )
Percolation Test Results Performed by Date
Test Pit No 1
::... ..._minuTZS per inch Depth of Test Pit _z � ,a Depth to ground ware- -97P it—e_ _.
Test Pit No. 2 minutes per inch Depth of Test Pit Depth to ground water
flow
Diameter
Total leaching area..
Total leaching hre-.
C 6 gallon.
Depth
L:.kL_sq. ft.
sq. ft.
Description of Soil_
Nature of Repairs or Alterations—Answer when applicable
Agreement
The undersigned agrees to install the aforedescrihed Individual Sewage Disposal System in accordance with
the provisions of Article RI 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 -.... X. 1\ ,... ,+-....r
Application Approved By %�
Application Disapproved for the following reasons' -
Dat/rll
/—
Permit No._.e.-1..:
Issued
11 Hit
THE COMMONWEALTH OF MASSACHUSETTS
BOARD OF HEALTH
OF
Certificate of Qlunt}tlianrr
THIS IS TO CERTIFY, That the Individual Sewage Disposal System constructed ( ) or Repaired ( )
by
m-e,uer
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.
DATP Inspector
THE COMMONWEALTH OF MASSACHUSETTS
BOARD OF HEALTH
t4 OF % 1r.`:.t-i!lbJ:: � :,
FEEL.: .l:.i
Bi ipnoal illorks (Cmtstrurtioa %irrmit
Permission us 1ereby granted it e
to Construct ((,� ) r Re lair ( ) an Indivikta# Sewage Disposal System
at No
as shown on the application for Disposal Works Construction Permit No 1 u-- Dated '
DATE
FORM 1 255 HOPES 8 WARREN. INC.. PUBLISHERS