Loading...
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