Lot 9 Septic Application & Plans CHECK OR FILL IN WHERE APPLICABLE
THE COMMONWEALTH OF MASSACHUSETTS
BOARD OF HEALTH
OF
FSS.
Appl ration fur Biipnsul Wurks CIunutrurtiun Permit
Application is hereby made for a Permit to Construct (" ) or Repair ( ) an Individual Sewage Disposal
System at:
LAratm,.Addrrse
or Lot No.
L
Owner ;r Address
' L. a G'
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.
Septic Tank—Liquid capacity gallons Length Width Diameter Depth
Disposal To nob-—No. 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—Answer when applicable
Agreement:
The utdersigned agrees to install the aforedescribed Individual Sewage Disposal System in accordance with
the provisio.ls of TITi.i: 5 of the State Sanitary Code—The undersigned further agrees not to place the system in
operation until a Certificate of Compliance has been isstKd b/the byaerof health
Signed
Application Approved B
Application Disapproved for the following reasons
Date.
1.e
flak
Permit No _ _r i Issued_
nu
Date
by
THE COMMONWEALTH OF MASSACHUSETTS
BOARD OF HEALTH
OF..
C�Crrtifirate IIf (IInmplittnrr
THIS IS TO CERTIFY, That the Individual Sewage Disposal System constructed ( ) or Repaired
Installer
at
has been instilled 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.
DATF Inspector
No C-C.
THE COMMONWEALTH OF MASSACHUSETTS
BOARD OF HEALTH
of r"
Oinpnuut morb @tnnntrurtinn Jrrmit
Permission ereby granted Vie
to Construct ( ) or Repair ( ) an Individual Sewage Disposal System
at No
strict
as shown on the application for Disposal Works Construction Permit No Dated 'f
DATE
FORM 1255 HoBBS & WARREN. INC., PUBLISHERS
Board of Health
•
_
1
. .