87 Septic Application & Permit 1971 CHECK OR FILL IN WHERE APPLICABLE
No..�._
THE COMMONWEALTH OF MASSACHUSETTS
BOARD. OF HEALTH
S._. . OF _. .
Applirtttinn fur 3Jispusttl 'U'arks @.Cnnwh nrtiun Permit
Application is hereby made for a Permit to Construct ( ) or Repair (' ) an Individual Sewage Disposal
System at: ..
Owner
/%t Installer Address
Size Lot Sq. feet
Type of Building
Dwelling—No. of Bedrooms Expansion Attic ( ) Garbage Grinder ( )
Other—Type of Building No. of persons Showers ( ) — Cafeteria ( )
Other fixtures gallons
Design Flow gallons per person per day. Total daily flow
Septic l Tank
Trench nc Liquid capacity Width Length
Width Diameter Depth
Disposal Trench—No. Width Total Length Total leaching area_ sq. ft.
Seepage Pit No Diameter Depth below inlet Total leaching area sq. ft.
Other Distribution box ( ) Dosing tank ( )
Date
Percolation Test Results Performed by Depth to ground water
Test Pit No. 1 minutes per inch Depth of Test Pit eP g
Test Pit No. 2 minutes per inch Depth of Test Pit Depth to ground water
or Lot No.
Address
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 agrees not to place the system in
operation until a Certificate of Compliance has been is;ued by the board,of health.r
Signed ................1_J. .
e: r
Application Approved By
Application Disapproved for the following reasons'
Permit No.. Issued.
Date
Date
d
by
THE COMMONWEALTH OF MASSACHUSETTS
BOARD OF HEALTH
`irrtifiratr of Tatty. liana
THIS.I ,TO CERTIFY, That the Individual Sewage Disposal System constructed ( ) or Repaired (' )
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 -,i_i dated t j
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 '
Espana
nrks Utnnstrurtian Vrrmit
Permission is hereby granted!
to Construct ( ) or Repair ( ) an Individual Sewage Disposal System
at No i'
Street
as shown on the application for Disposal Works Construction Permit No.r- Dated
r
DATE._... rl71' 1. 1/
FORM 1255 HOSSS 8 WARREN. INC.. PUBLISHERS
FEE'
Board of Health