Lot 16 Septic Application & Permit 1971 CHECK OR FILL IN WHERE APPLICABLE
No A FER.AS G 0
THE COMMONWEALTH OF MASSACHUSETTS
,( BOARD OF HEALTH
ea, OF j,4-1 fa-nrC:n
Application for §inpnnal rr;nrki Cllnnstrurtinn remit
Application is hereby made for a Permit to Construct ( ) or Repair ( ) an Individual Sewage Disposal
System at:
L
/114:17 ssalec
Own Address
Installer Address
Size Lot Sq. feet
Expansion Attic ( ) Garbage Grinder ( )
No. of persons Showers ( ) -- Cafeteria ( )
Type of Building
Dwelling—No. of Bedrooms
Other—Type of Building
Other fixtures
Design Flow //�� �gallons per person per day. Total daily flow gallons.
Septic Tank—Liquid capacityh ,ugallons Length Width Diameter De th
Disposal Trench--No Width Total Length Total leaching arc e 3T11k..sq. ft.
Seepage Pit No Diameter Depth below inlet Total leaching area sq. ft.
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 per inch Depth of Test Pit Depth to ground water
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 thfi board of health.
Signed;a (ray'tx'- f.:k`' ... �.-
Application Approved By ;. 1.�4H t:.l� :;I t-ec' _( _/ 7/
Application Disapproved for the following reasons' JJ
Permit No
Issued "' l• I 4 ..7/
Date
THE COMMONWEALTH OF MASSACHUSETTS
BOARD OF HEALTH
OF
Trrtifiratr of Tnmplianrr
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
CHECK OR FILL IN WHERE APPLICABLE
No
THE COMMONWEALTH OF MASSACHUSETTS
BOARD OF HEALTH
(, ,:...
OF
Applirntinn for ainpnnnl nrkni(knnntrurtinn Vrrmit
r:r;
Application is hereby made for a Permit to Construct ( ) or Repair ( ) an Individual Sewage Disposal
System at:
tir'
Installer
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 in _ gallons per person per day. Total daily flow gallons.
Septic Tank—Liquid capacitypr—ltigallons Length Width Diameter Depth
Disposal Trench—No. Width Total Length Total leaching area 6iLL.sq. ft.
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
/
or Lot No.
Address
Address
Seepage Pit No
Other Distribution box (
Percolation Test Results
Test Pit No. 1
Test Pit No. 2
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
elf
Application Approved By
Application Disapproved for the following reasons
Date
Permit No '
Date
Issued 412 t. 1 f LI 2/
Date