Lot 14 Septic Application & Permit ERE APPLICABLE
CHECK OR FILL IN
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THE COMMONWEALTH OF MASSACHUSETTS
BOARD
�fOF HEALTH
6114 OF / /cr'E-E-�ta174
Application fart ispnsal 1i irks Cnanntrurtinn Permit
Fait J'
Application is hereby made for a Permit to Construct (Y) or Repair ( ) an Individual Sewage Disposal
System at
or Lot lo.
Address
Installer U Address
Type of Building Size Lot Sq. feet
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 capacity is .:i_.igallons Length Width Diameter
Disposal Trench—No. Width Total Length Total leaching area
Seepage Pit No Diameter Depth below inlet Total leaching arc'
Other Distribution box ( ) Dosing tank ( )
Percolation Test Results Performed by Date
Test Pit No. ] 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
D
kh 0 0 sq. ft
sq. ft
Description of Soil
Nature of Repairs or Alterations—Answer when applicable
Agreement:
The undersigned agrees to install the aforedescribed Individual Sewage Disposal Svstetn 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 beenjssued by the board f,health.
Signed-O.-V-12 4.2-2c.1.0,2-4 " ///.Ltee.
qq
Application Approved By 3— �y.. x ..JZCV,_./d 7/
Application Disapproved for the following reasons-
Permit No % �' Issued )/cc16._J_1..I Y7
Dam
by
THE COMMONWEALTH OF MASSACHUSETTS
BOARD OF HEALTH
OF
Cifertifirole of Tinnylianre
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
No
THE COMMONWEALTH OF MASSACHUSETTS
BOARD OF HEALTH
.• ..a
Disposal r:i arks atonsirurtion hermit
Permission i_„hereby granted .�.m✓ �.-:�L `�'L
to Construct (K ) or,Repair ( ) an Individual Sewage Disposal stem
r
at No t
FEE.,..2 T u.(!
Street
as shown on the application for Disposal Works Construction Permit No..�
DATE
FORM 1255 HOBBS & WARREN. INC.. PUBLISHERS
Dated._..!__:...-�._. r
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