45 Septic Application & Permit CHECK OR FILL IN WHERE APPLICABLE
No 1 Fnx
THE COMMONWEALTH OF MASSACHUSETTS
BOARD OF HEALTH
OF
Application for fisposttl or tats Qlnnotrurtion hermit
Application is hereby made for a Permit to Construct ( ) or Repair ( Kan Individual Sewage Disposal
System at: _ l
Locae -Atlw♦io 4-
'2117,4 tz-Ctner )42/4 14:4
Installer
Type of Building
Dwelling— No. of Bedrooms
Other—Type of Building
Other fixtures
Design Flow
Septic Tank—Liquid capacity
Disposal Trench— No.
Seepage Pit No Diame
Other Distribution box
or Lot No.
Address
Expansion Attic
No. of persons
Address
Size Lot Sq. feet
Garbage Grinder ( )
Showers ( ) — Cafeteria ( )
gallons per person per day. Total daily flow gallons.
gallons Length Width Diameter Depth
Width Total Length Total leaching area sq. ft.
ter Depth below inlet Total leaching area sq. ft
Dosing tank ( )
Percolation Test Results Performed by
Test Pit No. 1 minutes per inch
Test Pit No. 2 minutes per inch
Description of Soil
Date
Depth of Test Pit Depth to ground water
Depth of Test Pit Depth to ground water
Nature ot4pail 4t Aleterati`ur Ansvye`when fippl c bl c
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 and ed f,t Cher agrees not to place the system in
operation until a Certificate of Compliance
Application Approved By
Application Disapproved for the following reasons'
I Date .,
U Date
Permit No
.Jf
Issued
Date
THE COMMONWEALTH OF MASSACHUSETTS
BOARD OF HEALTH
OF //. / IPAr> >1-2?
rrtifirate at (IInnf'plianre
THIS IS TO]CERTIFF, ,idual Sewage Disposal System constructed ( ) or Repaired ( )
by
at y
has been installed in accordance with the provisions of Article XI,f,The State Sanitarx)Ced as described, in the
application for Disposal Works Construction Permit No
/ ft
dated_ // I / e k
THE ISSUANCE OF THIS CERTIFICATE SHALL NOT BE CONSTRUED AS A iBUA ANTEE THAT THE
SYSTEM VIL L FUNCTION l S f6 T
ISFACTORY.
DATE A:"t od o Inspector --..) '' it"
No (
THE COMMONWEALTH OF MASSACHUSETTS
BOARD OF HEALTH
OF / le'Zia •p 7 j
FEE
Uispnanl 'Merits f rµu trurtian t3ermit
Permission is hereby grant
to Construct ( r) or RPtp r (,- ),an Individual Sewage Disposal System
at No 1 .::: _,,.•aJ ac-# kt; ::�✓
Street
as shown on the application for Disposal Works Construction Permits, I ! d_ ..� Dated ""
Board of Health
DATE
FORM 1255 HOBBS & WARREN. INC.. PUBLISHERS