5 Application & Permit 1976 ECK OR FILL IN WHERE APPLICABLE
No. 71/7
THE COMMONWEALTH OF MASSACHUSETTS
BOARD OF HEALTH
Fea �
Application -far fiupusul Works CnuttMrurtiun lfrrntit
Application is hereby"made for a Permit to Construct ( ) or Repair (4/aLn Indisidual Sewage Disposal
System at: --
Location-AAd .
or Lot No.
�p[-n >At-1 '—I
T,C QM-.'I cTIO e;c.
Installer Address
Type of Building
Size Lot Sq. feet
Dwelling—No. of Bedrooms Expansion Attic ( ) Garbage Grinder ( )
Other—Type of Building No of persona .----.----. Showers ( if — Cafeteria ( )
Other fixtures
Design Flow gallons per person per day. Total daily flow
Septic Tank--Liquid ca
Disposal Trench—No.
Seepage Pit No
Other Distribution box
Percolation Test Results
Test Pit No. I
Test Pit No. 2 minutes per inch
pacify gallons Length Width
Width Total Lengtl
Diameter Depth below inlet
Dosing tank ( )
Performed by
minutes per inch
gallons
Diameter Depth
Total leaching area
Total leaching arc sq. tt.
Description of Soil
Date
Depth of Test Pit Depth to ground water.
Depth of Test l'it Depth to ground water
Nature of Repairs or Alterations—Answer when applicable.:G PINcE J
Agreement:
The undersigned agrees to install the aforedescribed Individual Sewage Disposal System in accordance with
the provisions of Article NI 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 1 .,....'V>L� a....,..0
Application Approved By
Application Disapproved for the following reasons'
Permit No
7L/ 7
Issued
Date
Date
Date
Date
by
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
THE ISSUANCE OF THIS CERTIFICATE SHALL NOT BE CONSTRUED AS A GUARANTEE THAT THE
SYSTEM WILL FUNCTION SATISFACTORY.
DATF inspector
THE COMMONWEALTH OF MASSACHUSETTS
BOARD OF HEALTH
OF
Trrtifirate of Tontplianre
THIS IS TO CERTIFY, That the Individual Sewage Disposal System constructed ( ) or Repaired
tn,tanc
r\'o.1y./
Permission
to Construct
at No
as shown on the
THE COMMONWEALTH OF MASSACHUSETTS
BOARD OF HEALTH
it OF '/_a—Till.i rie
Disposal Works (nuntrurtina Permit
is hereby granted. . ¢ i
FE
or. Rrief( Lan IndyyYdual Sewage Disposal System
sent
7. _//_
application for Disposal Works Construction Permit No� 7 Dated /LA/—/ /
Board of Bearm frff
DATE
FORM 1255 HOURS & WARREN. I NC.. PUBLISHERS