22 Septic Application & Permit 1977 CHECK OR FILL IN WHERE APPLICABLE
No...;.._p.�
THE COMMONWEALTH OF MASSACHUSETTS
BOARD OF HEALTH
FEE
*pplirutintt forUfispnsttl Works Qinnstrurtinn Permit
Application is hereby'made for a Permit to Construct ( ) or Repair ( ' an lndih idual Sewage Disposal
System at:
eoemion-Add
Owner
/
•t 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 a Ilons
Design Flow gallons per person per day. Total daily flow gallons
Septic lank—Liquid capacitle u7Lg llons Length Width Diameter Depth
Disposal Trench
No Diameter Width Total Length Total leaching arc2_Ft.O ..sq. ft.
Seepage Pit No Diameter Depth below inlet Total leaching area s9. it
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
ground water to Depth ---
Test Pit No. 2 minutes per inch Depth of Test Pit Ue p g
or wt No
Address
Description of Soil
Nature of Repairs or Alterations—Answer when applicabl - c(ttL ._.er.. - "''+ `../44%
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
Date-/_F-/'..i
Application Disapproved for the following reasons
Permit No.._«_;.,., Issued
Date
Date
//
THE COMMONWEALTH OF MASSACHUSETTS
BOARD OF HEALTH
OF
Ta tirate of Tnmplianrr
THIS IS TO CERTIFY, That the Individual Sewage Disposal System constructed ( ) or Repaired
by 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
THE ISSUANCE OF THIS CERTIFICATE SHALL NOT BE CONSTRUED AS A GUARANTEE THAT THE
SYSTEM WILL FUNCTION SATISFACTORY.
DATF Inspector
NO
THE COMMONWEALTH OF MASSACHUSETTS
BOARD OF HEALTH
OF
U 'pooal Works tlln5trurtio t lirrmit
Permission is hereby granted_..
to Construct ( ) or Repair (o1 an Individual Sewage Disposal System
at No -..._ . ._ .._ . : . . . snee
as shown on the application for Disposal Works Construction Permit No
Datd
FEE
Board of Health
DATF
FORM 1255 HOBBS P. WARREN. INC.. PUBLISHERS