Lot 11/12 Septic Applications & Permits ERE APPLICABLE
OR FILL IN
No._'C' 1 Fee%S e
THE COMMONWEALTH OF MASSACHUSETTS
BOARD OF HEALTH
(t-t-t of
Appliration fo i�inpnttttl iflo
Application is hereby made for a Permit to Construct (
System at:
uustrurtinn Penult
) or Repair ( ) an Indhidnal Sewage D
posal
:ra ..24ft #/1
Type of Building
Dwelling—No. of Bedrooms Expansion Attic ( ) Garbage Grinder ( )
other—Type of Building No, of person= 5110 wcrs ( ) -- Cafeteria (
Other fixtures
A2Zrezz a LC or Lo: No.
LL
°w 27;4-4 I .allies:
Address
CIVamllcr
Size Lot Sq. feet
Design Flow gallons per person per day. Total daily flow
Seltic 'rank--Liquid capacitya57 gallons Length Width
Disposal Trench— No
Seepage Pit No Diameter Depth below inlet
gallon,
Diwnetcr De tl
idth_ ca L'I Total Length Si) Total leaching area 6 01 sq_ fr_
Total leaching taco sq. it
Other Distribution box ( ) Dosing tank ( )
Percolation Test Results Performed by Date
Test Pit No. 1 minutes per inch Depth of Test Pit Depth to ground water
Test Pit No. 2 minutes pc inch Depth of Test Pit Depth to ground water
Description of Soil
Nature of Repairs or Alteratinns—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 iu
operation until a Certificate of Compliance has been issued by the board of health.
Signed
Application Approved By ( . .t.ttI S t (j Zint-k :
12 Y
oars
Application Disapproved jor the following reasons' _
Permit No j
Issued
Oatt,
x{.ai-5tiy7T
by
THE COMMONWEALTH OF MASSACHUSETTS
BOARD OF HEALTH
OF
&ertifiratr of Qlnntplittnre
THIS IS TO CBS!IFY, That the Individual Sewage Disposal System constructed ( ) or Repaired ( )
.rmer
at
I:as been installed in accordance with the provision; of Article NI of The State Sanitary Code as described in the
application for Disposal Works Construction Permit No . dnted
THE ISSUANCE OF THIS CERTIFICATE SHALL NOT BE CONSTRUED AS A GUARANTEE THAT THE
SYSTEM WILL FUNCTION SATISFACTORY.
DATE inspector
by
THE COMMONWEALTH OF MASSACHUSETTS
BOARD OF HEALTH
OF
cgrrttfiratr of fdnmplianrr
THIS IS TO CERTIFY, That the Individual Sewage Disposal System constructed ( ) or Repaired
tdaaner
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 CERTIF'CATE SHALL NOT RE CONSTRUED AS A GUARANTEE THAT THE
SYSTEM WILL FUNCTION SATISFACTORY.
DATF Inspector
No
THE COMMONWEALTH OF MASSACHUSETTS
BOARD OF HEALTH
OF
lit
5purn4, Works (lion tqrurtinu 4lrrmit
Permission is Yereby-granted
to Construct-( „) or/Repair ( ) an Individlsze Dispo al System
at No - .. c_
FEE .1...
Street
D•
as shown on the application for Disposal Works Construction Pywyrt No �—'�� Dyed 4..i 1%77.
Ruud of health
DATE
FORM 1255 HOBBS B WARREN. INC.. PUBLISHERS
CHECK OR FILL IN WHERE APPLICABLE
Nola/ Fax /57 e c
THE COMMONWEALTH OF MASSACHUSETTS
{- /LBOARD �O� F HEALTH
/p itd1... OF !_'t5-C .:
.Apptiratinn for Eispnsd II arks QInnsfrnrtian 1lrrmit
Application is hereby made for a Permit to Construct (i-i or Repair ( ) an Individual Sewage Disposal
System at:
r_.
r�
.. ?
Type of Building
Dwelling—No. of Bedrooms Expansion Attic ( ) Garbage Grinder ( )
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 capacityn b..iallons Length Width Diameter De th
Disposal Trench—No. Width Total Length Total leaching area V Osq. ft.
Seepage Pit No Diameter Depth below inlet Total leaching area sq. ft.
Dosing tank ( )
Performed by Date
minutes per inch Depth of Test Pit Depth to ground water
minutes per inch Depth of Test Pit Depth to ground water
le
Address
Address
Size Lot Sq. feet
Other Distribution box (
Percolation Test Results
Test Pit No. I
Test Pit No. 2
Description of Soil
Nature of Repairs or Alterations—Answer when applicable
Agreement:
The undersigned agrees to install the aforedeseribed 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 begp issued by the bo rd of health.
Signed ' LC. I.S.L .... 11
Application Approved By - t!4.-4:d .�/ a f{.:t� -12&', 19`if-11
Application Disapproved for the following reasons'
by
Permit No '1ss
Date
Issued._ 7CV. if% /
Date/
THE COMMONWEALTH OF MASSACHUSETTS
BOARD OF HEALTH
OF
ftrrtifirtttr of f nmplittnrr
THIS IS TO CERTIFY, That the Individual Sewage Disposal System constructed ( ) or Repaired ( )
Wier
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
.• ........••
THE COMMONWEALTH OF MASSACHUSETTS
BOARD OF HEALTH
OF
Qtertifiratr of alomplianre
THIS IS TO CERTIFY, That the Individual Sewage Disposal System constructed ( ) or Repaired (
by
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
No...`.�.L..11
THE COMMONWEALTH OF MASSACHUSETTS
BOARD OF HEALTH
OF ti.JZY-. J .�:._.I. .
(1
flisponal IL arks finnnirxufion l'dermif
Permission is erehy granted . a .. :;i.
to Construct ( or Repair ( ) an Individual Sewage Disposal stem
at No E .: 1
PEE/4. `4
Street
as shown on the application for Disposal Works Construction Patina No..:;,/ f Dated_) .:rr..1.j...1./ f
7 B doi Health.
DATE
FORM 1255 HOBBS & WARREN. INC.. PUBLISHERS
CHECK OR PILL IN WHERE APPLICABLE
No
THE COMMONWEALTH OF MASSACHUSETTS
BOARD OF HEALTH
C/ 7Y OF__.et/NC 7t14<n,>roet:
Pas
Applirativa for fiopusal itinrko (toaeftrttrtiva Permit
Application is hereby made for a Permit to Construct (✓) or Repair (
System at:
Teo.eea1LE ,Qs
) an lad is khan Sewage Disposal
y ..Location•Address or Lot No.
Owner Address
Installer Address
Type of Building Size Lot/7«00 ± e, feet
Dwelling—No. of Bedrooms 3 Expansion Attic ( ) Garbage Grinder ( )
Other--Type of Building No. of persons Showers ( ) -- Cafeteria ( )
Other fixtures
Design Flow gallons per person per day. Total daily flow galons.
Septic Tank—Liquid capacity gallons Length Width Diameter Depth
Disposal Trench—No Width Total Length Total leaching aze; sq. ft.
Seepage Pit No Diameter Depth below inlet Total leaching area sq. ft.
) Dosing tank ( )/
Performed by ✓•f%9ierite. Z.F11v
rinutes per inch Depth of Test Pit 3o "
Other Distribution box (
Percolation Test Results
Test Pit No. IL..P
Test Pit No. 2
+.AurLYhzDate 7"V2/
Depth to ground water_A/0 /C
minutes per inch Depth of Test Pit 6 'o t, Depth to ground water 4-'104/E
Description of Soil 0-;t" Tov'6uie O c ` j7LT S�¢"'J 4 c4O F 6;e41E2 « TN C,%'ets
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'
Dae
Data
Date
Permit No Issued
Date