72 Septic Application & Permit 1982 CHECK OR FILL IN WHERE APPLICABLE
No 6'
THE COMMONWEALTH OF MASSACHUSETTS
BOARD OF HEALTH
Otte- OF
Apptiratimifor Dismal librks Turtutrartion Vault
Application is hereby made for a Permit to Construct ( ) or Repair ( Gran Individual Sewage Disposal
System at:
z.ae S-
riocatiosts AddAyss
Owneirs,-
1Yr.v
u..7 •
tyz:y fitet.„
Installer Address
Type of Building __ Size Lot Sq. feet
Dwelling—No of Bedrooms -- Expansion Attic ( ) Garbage Grinder ( '-3--
Other—Type of Building No. of persons Showers ( ) — Cafeteria ( )
Other fixtures
Design Flow gallons per person per day. Total daily flow gallons.
Septic Tank—Liquid capacity gallons Length Width Diameter Depth
Disposal Trench—No. Width Total Length Total leaching area sq. ft.
Seepage Pit No Diameter Depth below inle• Total leaching area sq. ft.
Other Distribution box ( ) Dosing tank ( )
Percolation Test Results Performed by Date
Test Pit No. I minutes per inch Depth of Test Pit Depth to ground water
Test Pit No. 2 minutes per inch Depth of Test Pit Depth to ground water
Description of Soil
r • i( 74:7 ti id zi
Nature of Repairs or AltzeLions—Answer when applicable
24./ /b men. t•-s-u.•
Agreement:
The undersigned agrees to install the aforedescribed Individual Sewage Disposal System
the provisions of nTLL 5 of the State Sanitary Code— The undersigned further agrees not to
operation until a Certificate of Compliance has been issued y he board of health.
Sign, /
Application Approved By 1- :___,, . • Y L-1)----
Application Disapproved for the following reasons
in accordance with
place the system in
, Dat
('
ate
Permit No - Issued. 4
THE COMMONWEALTH OF MASSACHUSETTS
/, BOARD OF HEALTH 'L
(,.,G,G.1 OF j, .. / //e_.-----4 d r
OIrrtifirtttr of QQnmpltttnrr
THIS IS TO CERT( , That th n dual(Sewage Disposal System constructed ( ) or Repaired (
by 1 %X
at
been installed in accordance with the pro-visions of TITLE. 5 of,1I>,e State Sanitary Code a deser�ed in the
application for Disposal Works Construction Permit No._..d L �--- dated 11.(Y/e- -""
THE ISSUANCE OF THIS CERTIFICATE SHALL NOT BE CONSTRUED AS A GUARANTEE THAT THE
SYSTEM WILL FUNCTION SATISFACTORY. %
DATE 7 - y_, Inspector 71"::, 1
THE COMMONWEALTH OF MASSACHUSETTS
BOARD OF HEALTH
- 1. ,
No
flinposttl rEnrkn Tnnstrwtinn tirrntit
Permission is hereby granted J...il.!.i_5..,:_LCi to Construct ( ) or Repair ( man Indirid Sev(age Disposal System
at No 7` .l.re._.. c2.'r
street
as shown on the application for Disposal Works Construction Permit No i ' "Dated�y
�R oar a of Healti�
DATE T ` �.d--_
FORM 1255 HOBBS & WARREN. INC., PUBLISHERS