92 Septic Application & Permit 1978 CHECK OR FILL IN WHERE APPLICABLE
No ......._
THE COMMONWEALTH OF MASSACHUSETTS
BOARD OF HEALTH
OF
FEE
.Apptiratigu for flispoont iliorlus Clonstrurtion rrrusit
Application is hereby made for a Permit to Construct (- ) or Repair ( ) an Individual Sewage Disposal
System at:
oration•Address or Lot No.
Owner
t
-- F-
Instalter L' 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 capacifry.-:✓:a!_.gallons Length Width Diameter Depth
Disposal Trench—No. Width.,-,..,12 Total Length -I I Total leaching area.._- 0 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
Address
Seepage Pit No
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 undersigned agrees to install the aforedescribed Individual Sewage Disposal System in accordance with
the provisions of:ITC 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 y:kit.;
Application Approved By
Date
Date
Application Disapproved for the following reasons-
Permit No._.¢....:
Date
Issued.
by
at
THE COMMONWEALTH OF MASSACHUSETTS
BOARD OF HEALTH
OF
(Rertifirafr of (Compliant
THIS IS TO CERTIFY, That the Individual Sewage Disposal System constructed (.7)-or Repaired
has been installed in accordance with the provisions of TITLE 5 of The State Sanitary Code as described in the
application for 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 '
THE COMMONWEALTH OF MASSACHUSETTS
BOARD OF HEALTH
OF
Binomial Marko tdonstrnrtion ljrrmit
Permission is hereby granted
to Construct ( ) or Repair ( ) an Individual Sewage Disposal System
FEE
Street
as shown on the application for Disposal Works Construction Permit No Dated
Board of Health
DATE
FORM 1255 HOBBS 8 WARREN, INC.. PUBLISHERS