312 Septic Application & Permit 1973 ECK OR FILL IN WHERE APPLICABLE
No.
THE COMMONWEALTH OF MASSACHUSETTS
BOARD OF HEALTH
OF f -
c
Application for Biannual rrurii Tonnfrurtiun Prima
Application is hereby made for a Permit to Construct ((Ivor Repair ( ) an Individual Sewage Disposal
System at:
Location.Address. - or Lot No.
]# d
0 ar.;-
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.r.
Septic Tank—Liquid capacity: gallons Length Width Diameter Depth
Disposal Trench—No. Width Total Length Total leaching area._..y.,a_.ilsq. ft.
Seepage Pit No Diameter Depth below inlet Total leaching area....711/..sq. ft.
Other Distribution box ( ) Dosing tank ( )
Percolation Test Results Performed by Date
Test Pit No. I 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:
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 -
Application Approved By
v Date
Application Disapproved for the following reasons•
Permit Na...,..!K:of Issued.
Date
Date
THE COMMONWEALTH OF MASSACH U SETTS
BOARD OF HEALTH
OF tflf.
Tertifirat of To liana
THIS IS TO CE$TgY, That the Individual Sewage Disposal System constructed r ) or Repaired
by ADA& i...4......traaget
Installer
L
at. -
4 1 a
has been installed in a cordance 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 I 1.3 Inspector 444fral,'er 9rattent4
THE COMMONWEALTH OF MASSACHUSETTS
BOARD OF HEALTH
OF
Disponi nrks Ottatruttinit hermit
Permission ii-itereby granted c •
to Construct ( ) Pewit, age Disposal System
at No -
FEE./
Street
as shown on the application for Disposal Works Construction Permit - Dated
DATE
FORM 1255 HOBBS & WARREN. INC.. PUBLISHERS
Board of II:Sank