Lot 8 Septic Application & Plans No...:.-
THE COMMONWEALTH OF MASSACHUSETTS
BOARD OF HEALTH
OF
FESF..Da.
Appliratinn far Uispnzai Tfinrks Tonntrurtinn Permit
Application is hereby made for a Permit to Construct (° ) or Repair ( ) an Individual Sewage Disposal
System at:
Location-Address
Owner
or Lot No.
Address
PIInstaller tJ Address
6 Type of Building Size Lot Sq. feet
nDwelling—No. of Bedrooms Expansion Attic ( ) Garbage Grinder ( )
pa, Other--Type of Building No. of persons Showers ( ) — Cafeteria ( )
a. Other fixtures
al
Design Flow gallons per person per day. Total daily flow gallons.
g Septic Tank—Liquid capacitg,.."•' gallons Length Width Diameter Depth
xDisposal Tn nch-No. Width Total Length Total leaching area sq. t
Seepage Pit No / Diameter Depth below inlet Total leaching area/Z ,i
X Other Distribution box ( ) Dosing tank ( ) t' •r`ei(
Percolation Test Results Performed by Date
,■"lj Test Pit No. 1 minutes per inch Depth of Test Pit Depth to ground water
W Test Pit No. 2 minutes per inch Depth of Test Pit Depth to ground water
W
U Description of Soil
W
U
al
UNature of Repairs or Alterations—Answer when applicable
Agreement:
The ul.dersigned agrees to install the aforedescribed Individual Sewage Disposal System in accordance with
the provisions of 2.__._. 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
Application Approved By
Application Disapproved for the following reasons•
Date
r I /
Date '
Permit No - Issued
Date
by
THE COMMONWEALTH OF MASSACHUSETTS
BOARD OF HEALTH
OF
Cnertifirntr of Clumplianre
THIS IS TO CERTIFY, That the Individual Sewage Disposal System constructed ( ) or Repaired
)
Installer
at
has been installed in accordance with the provisions of TITLE 5 of The State Sanitary Code as described in the
application f r 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 Inspector
No !
THE COMMONWEALTH OF MASSACHUSETTS
BOARD OF HEALTH
OF / 41 41._
fliupnuat 3 nr1w tannutrurttun jrrmif
FEE,.._ O '
Permission is hereby granted
to Construct ( ) or Repair ( ) an Individual Sewage lZposal System
at No :t. .- 4 Street
as shown on the application for Disposal Works Construction Permit No Dated
Board of Hrslth
DATE
FORM 1255 HOBBS 8 WARREN. INC.. PUBLISHERS
f