169 Septic Application 1969 by
THE COMMONWEALTH OF MASSACHUSETTS
BOARD OF HEALTH
OF
satrrtifirato of tdnmplitttur
THIS IS TO CERTIFY, That the Individual Sewage Disposal System constructed ( ) or Repaired (//5/
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 v 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
OF
Tis}Tnnttl 311nrks Q nnstrurtinn hermit
FEE
Permission is hereby granted
to Construct ( ) or Repair (r/S an Individual Sewage Disposal System
at No
Street
as shown on the application for Disposal Works Construction Permit No. Dated
DATE
FORM 1255 HOBBS & WARREN. INC., PUBLISHERS
1
Board of Health
ERE APPLICABLE
z
c5
0
V
THE COMMONWEALTH OF MASSACHUSETTS
BOARD OF HEALTH
OF
FEE
Appliratinn far fTinpnmal 313nrks Qtnnntrurtinn tirrmit
Application is hereby made for a Permit. to Construct
System at:.
Location-Address
I. _Owner
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 Melt Depth of Test Pit Depth to ground water
or Repair (/can Individual Sewage Disposal
or Lot No.
Address
Description of Soil
Nature of Repairs or Alterations—Answer when applicable
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 health.
Signed
-Date
Application Approved By
._.............t 1.
to
Application Disapproved for the following reasons•
Permit No Issued
Date
Date