Lot 153 Septic Application & Permit CHECK OR FILL IN WHERE AP
No 11625
THE COMMONWEALTH OF MASSACHUSETTS
BOARD 33OF��/HE�-�A{{LTH
(6c.ttb.. OF J-1'e:" ae J
Appliratinn fur Elinpusttl Harks Tuna-union
FEE..../-J'
nntit
Application is hereby made for a Permit to Construct (✓ ) or Repair ( ) an Individual Sewage Disposal
System at:
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 capacitPi d gallons Length Width Diameter De th
Disposal Trench—No. Width Total Length Total leaching area . IO...sq. 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
net
attlaZati
Installer
or Lot Na.
e „J Address
L14. t.?/..
Address
Size Lot Sq. feet
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 sued by the board of health.
Signed
Application Approved By
Application Disapproved for the folio
g reaso
s
Permit No
Da:c
i.4I,.LLZ/
Date
by
THE COMMONWEALTH OF MASSACHUSETTS
BOARD OF HEALTH
OF . . . . ... . . .. ......... . . ....
Trrtifirtttr of (IInmplittnrr
THIS IS TO CERTIFY, That the Individual Sewage Disposal System constructed ( ) or Repaired ( )
m,taner
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 a3
THE COMMONWEALTH OF MASSACHUSETTS
BOARD OF HEALTH
C.. Cj. OF. /,G'.R'!/
i isgns iJ nrks //Otnnstr�Litrtinrn lJermit
Permission i ereby granted 4,.carkr �4::!`!-u..= --L_[.'x.d.sa.e.&3 .
to Construct ( or Repair ( ) an Individual Seovage Disposal System
at No i :_./_..3 .Lcskr ._:
Street
as shown on the application for Disposal Works Construction Perstr No..44.6.) Dated-
' Q .6-%:t-._91
Board of
DATE
FORM 1255 HOSES & WARREN, INC., PUBLISHERS
FEE.J� �°
97i