60 Application & Permit 1972 CHECK OR FILL IN WFIERE APPLICABLE
Fn.....
THE COMMONWEALTH OF MASSACHUSETTS
BOARD OF HEALTH
OF ,.
L
Application Lai Espanol Hocks Qnnatrurtinn ?jlerntit
Application is hereby made for a Permit to Construct ( ) or Repair ( ' an Individual Sewage Disposal
System at:
Location"Address or Lot No.
�I Ower Address
°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 capacity gallons Length Width Diameter Depth
Disposal Trench—No Width Total Length Total leaching area sq. 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
Description of Soil
Nature of Repairs or Alterations—Answer when applicable J:!':.1.f.d re.C:Pi"°.?:C4
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 issued by the board of hgalth.
Signed
Application Approved By
Application Disapproved for the following reasons•
6
Permit No
Issued. v : -
Dat
or Datt
Dat
Date
by
THE COMMONWEALTH OF MASSACHUSETTS
BOARD OF HEALTH
OF
&rtifiratr of Tompliuurr
THIS IS TO CERTIFY, That the Individual Sewage Disposal System constructed ( ) or Repaired
Listaller
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
THE COMMONWEALTH OF MASSACHUSETTS
BOARD OF HEALTH
C
OF
3ispuoul I orbs Trinstrurtion Jrrmit
Permission is hereby granted/.._
to Construct ( ) or Repair ( -'I + Individual' Sewage Disposal System
at No
FEa
Street
as shown on the application for Disposal Works Construction Permit No _ - Dated
Board of Health
DATE
FORM 1255 HOBBS & WARREN. INC.. PUBLISHERS