Septic Applications & Permits CHECK OR FILL IN WHERE APPLICABLE
No._2.6...�/.
THE COMMONWEALTH OF MASSACHUSETTS
BOARD OF HEALTH
Appliratinu fur Blain/gal
h 1
Fits
arks Olunstrurtinn tirrmit
Application is hereby made for a Permit to Construct ( ) or Repair (v an Individual Sewage Disposal
System at:
�' YY Location•Addres
•
or Lot No.
Owner 1 `71; Addr?, i..-
•
•
Installer Address
Type of Building s 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.,z:.. Lgallons Length Width Diameter Depth
Disposal Trench—No. Width Total Length Total leaching area a.cC 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: 7
The undersigned agrees to install the aforedescrihed 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 � - e ,.�
Date
Application Approved By - ,,tz.grzl
Application Disapproved for the following reasons.
Permit No.36.7
Issued
Daze
Date
Date
THE COMMONWEALTH OF MASSACHUSETTS
BOARD OF HEALTH
OF _t,:i zyy..i
Okrttfuntr of f m*pltanrr
Tills IS TO CERTIFY, That the Individual Sewage Disposal System constructed ( ) or Repaired (✓)
7 i
by 'Lc. f Instiller
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 f dated THE ISSUANCE OF THIS CERTIFICATE SHALL NOT BE CONSTRUED AS A GUARANTEE THAT THE
SYSTEM WILL FUNCTION SATISFACTORY.
DATE i ,;::.Y Inspector..:).;;;:H:'! 1 %d.
THE COMMONWEALTH OF MASSACHUSETTS
BOARD OF HEALTH
OF
Utspasnl
rr;
arks Qlnnstrurtinn lgermit
Permission is hereby granted
to Construct ()(„) or Repair ( ) an Ipdividuaf Sewage Disposal 5 stem
at No
FEE
Street
as shown on the application for Disposal Works Construction Permit No Dated %
DATE
FORM 1255 HOBBB fi WARREN. INC.. PUBLISHERS
Bard of Ht lth
'J
7144 ai)
CHECK OR FILL IN WHERE APPLICABLE
No ILVia-
THE COMMONWEALTH OF MASSACHUSETTS
BOARD OF HEALTH_
Application for 3Jiupuutti Works Cionotruction f ermi#
Application is hereby made for a Permit to Construct ( ) or Repair (L-J an Individual Sewage Disposal
System at: ,
Location-Addhts -
her
or Lot No.
Address
Installer Address
Type of Building Size Lot Sq. feet
Dwelling—No. of Bedrooms i Expansion Attic ( ) Garbage Grinder ( )
Other—Type of Building No. of persons (ix Showers ( ) — Cafeteria ( )
Other fixtres
Design Flow gallons per person per day. Total daily flow gallons.
Septic Tank—Liquid capacity gallons, Length Width Diameter Depth
Disposal Trench—No. -1 Width - Total Length Total leaching area sq. ft.
Seepage Pit No Diameter Depth below inlet Total leaching area sq. ft.
Dosing tank ( )
Performed by Date
minutes per inch Depth of Test Pit Depth to ground water
minutes per inch Depth of Test Pit Depth to ground water
Other Distribution box
Percolation Test Results
Test Pit No. I
Test Pit No. 2
Description of Soil
Nature of Repairs or Alterations—Aire r when applicable res-`"
Agreement:
The undersigned agrees to install the aforedescribed Individual Sewage Disposal System in accordance with
the provisions of TITLE 5 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
t
Application Approved By
Application Disapproved for the following reasons'
Permit No
Issued '1 '
1
Pat
Date
Date
Daze
THE COMMONWEALTH OF MASSACHUSETTS
BOARD OF—HEALTH
�j,
OF MI Qtrrtifiratr of ( nmplianre '" �
by THIS IS 0 CER Y, T he (livid Se age Disposal System constructed ( ) or Repaired t✓l
at i st
�1 .'y"
C.
has has been installed in accordance with the provisions of TITLE 5 of sate Sanitary Cod as descrkhed in the
application for Disposal Works Construction Permit No ��' d��-- dated Cr 3a G Y
THE ISSUANCE OF THIS CERTIFICATE SHALL NOT BE CONSTRUED AS A GUARANTEE THAT THE
SYSTEM WIL UNCTION SATISFACTORY.
DATE T �!
No
Inspector
THE COMMONWEALTH OF MASSACHUSETTS
BOARD OF HEALTH
OF Y� u_ a r 1: _ _ °-
3flis,pnsat Works @iunatrurtinn Permit
Permission is hereby granted
to Construct( (-) or Repair fr ) an Individual Sewage Disposal System.!
FEE/7
reet
as shown on the application for Disposal Works Construction Permit No Dated �-
DATE
FORM 1255 HOBBS t WARREN, PUBLISHERS
mMa—d? Health