Lot 150 Septic Application & Permit ECK OR FILL IN WHERE APPLICABLE
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THE COMMONWEALTH OF MASSACHUSETTS
1-BOARD OF HEALTH
Appliratinn fur lispnsttl l urks Qtnnstrurtinn IJrrutit
Application is hereby made for a Permit to Construct
System at:
wk. C` f
Installer 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 capacit}4a5-6gallons Length Width Diameter Depth
Disposal Trench—No. Width Total Length Total leaching area.-_e1COsq. 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
(I
or Repair ( ) an Indic idual Sewage Disposal
15�
or Lot No.
Address
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 be issued the board of health.
Signed gb{L C .t sc. //
Application Approved By ..2k %c/- :f->f .3.f_L(17
Application Disapproved for the following reasons
Permit No 7..(<v;--
pate
Issued 6C
U Date
by
THE COMMONWEALTH OF MASSACHUSETTS
BOARD OF HEALTH
OF
(IIertifirate of Olnwptittttrr
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
/' / y� BOARD OF HEALTH
4 9'- l tZtt. .. OF -1/.4I-1Rb.?pfa:% . a
No C
FEE �r
flinpnsuL!nrks_ @tpttntrurtinnjerntit
Permission iytiiereby granted._-:.G4i yy�>� £4tiu:L EE"1ti2-fhd—Cti i
to Construct Iv) or Rc air ( Individual-?S `age Disposal System
at No Ei �.�_.✓T..�:I11s-PY.i.'H{r' _
Street q /
as shown on the application for Disposal Works Construction Pe No... (y:., ..... bated-_v_ L.4q.%rl.. l..
DATE
FORM 1255 HOBSS & WARREN. INC.. PUBLISHERS
Boat d.of