Misc. Septic Application 2 CHECK OR FILL IN WHERE APPLICABLE
No % FEE
THE COMMONWEALTH OF MASSACHUSETTS
BOARD OF HEALTH
I I _ OF lr � 1) .t;.rr 1 r.
Appliratinn for Tisponni rrnrka (!nnstrnrtinn Permit
Application is hereby made for a Permit to Construct ( ) or Repair ( ) an Individual Sewage Disposal
System at:
4:01.
Address
Ins.aIT 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 capacityLQ gallons Length Width Diameter Depth
Disposal Trench—No Width Total Length Total leaching area /SO 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
Agreement: t
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 health. ,
Signeg f
Application Approved By :}r-F . !['. >>' d h. Cv't i..-51)7r.(!.
� m
Application Disapproved for the following reasons
Permit No
Dam
Issued._.}2AL1 Date /eY
J nm
by
at
has been installed in accordance with the provisions of Article XI of The State SnnitaryyCocde as described in the
application for Disposal Works Construction Permit No /7- V dated )a"' .
THE ISSUANCE OF THIS CERTIFICATE SHALL NOT BE CONSTRUED AS A D,UARANTEE THAT THE
SYSTEM WILL FUNCTION SATISFACTORY.
DATE - / � Inspector
THE COMMONWEALTH OF MASSACHUSETTS �y
pp BOARD OF HEALTH
OF /In. X.7/:.p 611
Qrrtifirtttr of &mindittnrr
THIS I$TO CERTIFY, That the Individual Sewage Disposal System constructed (" ) or Repaired
fInsfaijat
THE COMMONWEALTH OF MASSACHUSETTS
BOARD OF HEALTH
OF
O FEE
�in}Tnsttl 3finrkn CIinnntrurtium
or 4Jrrmi
Permission iyfierelry granted
i/
to Construct ( ) Repair ( . ) an Individual Sewage Disposal System
at No
Street
as shown on the application for Disposal Works Construction Permit No
DATE
FORM 1255 HOBBS & WARREN. INC.. PUBLISHERS
Doan].