Lot 149 Septic Application & Permit CHECK OR FILL IN WHERE APPLICABLE
No 4,/i I Fna 0
THE COMMONWEALTH OF MASSACHUSETTS
BOARD OF HEALTH
6
Apptiratinn far Tinpnnal hurls Cimuirnrtinn 1ermit
Application is hereby made for a Permit to Construct ( ) or Repair ( ) an Individual Sewage Disposal
System at: -7)
,c11La.`.✓!'S1^-"-6`E- L1?11:t 'uce .
Ile
Type of Building
Dwelling—No. of Bedrooms
Other—Type of Building
Other fixtures
Design Flow
Septic Tank—Liquid capacity
Disposal Trench—No.
Address
Addrets
Size Lot Sq. feet
Expansion Attic ( ) Garbage Grinder ( )
Showers ( ) — Cafeteria ( )
No. of persons
gallons per person per day. Total daily now gallons.
gallons Length Width Diameter Depth
Width Total Length Total leaching area s..ICI.Q.sq. ft.
Total leaching area sq. ft.
Seepage Pit No Diameter Depth below inlet
Other Distribution box ( ) Dosing tank ( )
Percolation Test Results Performed by
Test Pit No. I minutes per inch Depth of Test Pit
Test Pit No. 2 minutes per inch Depth of Test Pit
Date
Depth to ground water
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 b issued b the board of health.
L/i r/"�j/
Application Approved By
Signed
Application Disapproved for the following reasons•
Date
Permit No l k f Issued..i"-1�% E t'='I 1 1 971
Date
by
THE COMMONWEALTH OF MASSACHUSETTS
BOARD OF HEALTH
OF
Certificate of Toniplianre
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
THE COMMONWEALTH OF MASSACHUSETTS
BOARD OF HEALTH
f et L Vet ati.tr yf FEE/S;
Malmo ul�or�ks k`io/nsfrnrtito�n Permit
Permission i ereby granted i . .. . a.:.,l :+.xn-:x.-.L.e?Io=t t
to Construcct( )kr Repair ( an Individ h Sewage Disposal System
at No iTgst
snore'
as shown on the application for Disposal Works Construction Pe t No. $.)
DATE
FORM 1255 HOBBS & WARREN. INC.. PUBLISHERS
Roe l of