22 Septic Application es
Sc.
CHECK OR FILL IN WHERE APPLICABLE
THE COMMONWEALTH OF MASSACHUSETTS
BOARD OF HEALTH
/(/o,e r!/AmproA/
c qT-Y OF
Fits
Appel ration for Uispnsal cr;arks Clottstrttrtinn permit
Application is hereby made for a Permit to Construct (✓) or Repair ( ) an Individual Sewage Disposal
System at: _ _ 4
-LL/lC
/. I - i 44- Z No.
;.l/}/G Address
Installer nna ess �t
Type of Building Size Lot (9,. 229 Sq. feet„
Dwelling-No. of Bedrooms 3 Expansion Attic ( ) Garbage Grinder (✓)
Other-Type of Budding No. of persons Showers ( ) - Cafeteria ( )
Other fixtures
Design Flow tr70 gallons per person per daa. Total daily flow eQ.C✓ gallons.,
Septic Ta = liquid capacityl&..gallons Length.l62-0 Width.5. r Diameter Depth. r." .....¢..
Disposal �-No. ( Width..J S r Total Length +C' I Total leaching area-_&iO sq. ft.
Seepage Pit No Diameter Depth below inlet Total leaching area sq. ft.
Other Distribution box ( ) Dosing tank ( )
Percolation Test Results Performed by.Cit?r4z2=A1/..t.P.5 '1 A4'rata?'.. Date. J�/2'/F4'
Test Pit No. 1 d• 33 minutes per inch Depth of Test Pit 411.-0 n Depth to ground water NO Al
Test Pit No. 2 minutes per inch Depth of Test Pit...3 -Q e Depth to ground water NoNf
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 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 B
Application Disapproved for the following reasons
Date
Date
Date
Permit No Issued.
Date
by
THE COMMONWEALTH OF MASSACHUSETTS
BOARD OF HEALTH
OF
(ltrrtifirate of fdnmptianre
THIS IS TO CERTIFY, That the Individual Sewage Disposal System constructed ( ) or Repaired ( )
Installer
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