Lot 13 Septic Application Permit & Plans ERE APPLICABLE
CHECK OR FILL IN
No '
THE COMMONWEALTH OP MASSACHUSETTS
BOARD OF HEALTH
OF__
Applutttinn for %isp od
rr;
arks tlnnstrurtinn hermit
Application is hereby made for a Permit to Construct ( ) or Repair ( ) an Individual Sewage Disposal
System at:
Loonwr-Addno
Owner .,
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
Other Distribution box
Percolation Test Results
Test Pit No. I
Test Pit No. 2
or ld Nn
Address
Address
Size Lot Sq. feet
Expansion Attic ( ) Garbage Grinder ( )
No. of persons Showers ( ) — Cafeteria ( )
gallons per person per day. Total daily flow -gallons.
gallons Length Width Diameter Depth..,,,.
Width Total Length Total leaching area.........Lt,' sq.ft•
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
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 jgrees not to place the system in
operation until a Certificate of Compliance has been issued by thiq board of
Signed`_
Application Approved By
Application Disapproved for the following reasons'
Permit No ,
Issued
Date
by
THE COMMONWEALTH OF MASSACHUSETTS
BOARD OF HEALTH
Trttifirate of (lCnntptiatue
THIS I TO cERTG(FY,tThat.the Individual Sewage Disposal System constructed (r ) or Repaired
/ . n • f 4st,.t .I
Installer
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 ,3-V dated..jlt 1i ' /EJ
THE ISSUANCE OF THIS CERTIFICATE SHALL NOT BE CONSTRUED AS A GUARANTEE THAT THE
SYSTEM WILL FUNCTION SATISFACTORY. //_,, y,
DATF > ) V ( �E,3 kr/.Inspector ?y.,/ar-as^*jf.l4.i
1 "1
THE COMMONWEALTH OF MASSACHUSETTS
BOARD OF HEALTH
OF. /I -
Bisons* i�harknSOnantrtutinn Permit
Permission is hereby granted
to Constrttct (irl or Repair ( ) an_Individual'Sewage Disposal System
at No
FEE.
Street
as shown on the application for Disposal Works Construction Permit No
DATE
FORM 1255 Hosas & WARREN. INC.. PUBLISHERS
Dated
Hoard of Health
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