87 Septic Application 1975 ERE APPLICABLE
CHECK OR FILL IN
No 96
THE COMMONWEALTH OF MASSACHUSETTS
BOARD OF HEALTH
OF
Fax �4V
1 ppliratinn fur fiopum'al Wnrk.' Tnustrurtinn Permit
Application is hereby made for a Permit to Construct (
System at:
T
Ivmaev 9Ldiess
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 gtdlons per person per day. Total daily flow gallons.
Septic Tank—Liquid capacity gallons Lone h Width Diameter Depth
Disposal Trench—No. Width Total Length Total leaching area sq. L.
Seepage Pit No Diameter Depth below inlet Total leaching area sq. It
) Dosing tank ( )
Performed by - Date
¢inutes per inch Depth of Test Pit Depth to ground water
minutes per inch Depth of Test Pit Depth to ground water
) or Repair (t/) an Individual Sewage Disposal
or Lot Ne.
Address
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 Jaod /,,„ etirma
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 i. ed by the board of health.
Application Approved By
Signed.
«D ` Llf7s
Application Disapproved for the following reasons'
Permit No._IQ..1 a
//��p � Date
Issued._ riti. _.t.9.Z,.i
Date
by
THE COMMONWEALTH OF MASSACHUSETTS
BOARD OF HEALTH
(1Lertifirate of flninplianre
THIS 1S TO CERTIFY, That the Individual Sewage Disposal System constructed ( 1 or Repaired (
)
at
has been installed in accordance with the provisions of :Article X1 of The State Sanitary Code as descrihed in the
application for Disposal Works Constriction Permit No «meal
THE ISSUANCE OF THIS CERTIFICATE SHALL NOT BE CONSTRUED AS A GUARANTEE THAT THE
SYSTEM WILL FUNCTION SATISFACTORY.
DAT F Inspector