Misc. Lot 5 Septic Application & Permit CHECK OR FILL IN WHERE APPLICABLE
No
THE COMMONWEALTH OF MASSACHUSETTS
BOARD OF HEALTH
•
OF ."FS
rTht
FEE L
Applirntinn fur 3Jispunat I16 arks Qtunstruttinn lrrmit
Application is hereby made for a Permit to Construct (' ) or Repair
System at:
r
/e
ton
Type of Building
Dwelling—No. of Bedrooms
Other—Type of Building
Other fixtures
Design Flow — ) gallons
Septic Tank—Liquid capacity( -' -' 1gallons
Disposal Trench—No. Width
Seepage Pit No Diameter
Dosing tank ( )
Ovr eet
' Y
an Individual Sewage Disposal
or Lot No.
ZInstaller Asarus
Size Lot Sq. feet
Expansion Attic ( ) Garbage Grinder ( )
No. of persons Showers ( ) — Cafeteria ( )
per person per day. Total daily flow — J gallons.
Length Width Diameter Depth
Total Length Total leaching area to" -sq. ft.
Depth below inlet Total leaching area - sq. ft.
Other Distribution box
Percolation Test Results
Test Pit No. I
Test Pit No. 2
Performed by Data
minutes per inch Depth of Test Pit Depth to ground water
minutes per inch Depth of Test Pit Depth to ground water
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 issued by the board of healthy,
✓
Signed
Date
Application Approved By
Application Disapproved for the following reasons
Permit No
Date
Date
Issued •- ' / /
Date
THE COMMONWEALTH OF MASSACHUSETTS
BOARD OF HEALTH
Li or
(grrtifiratr of elompliatur
THIS IS TO c4RTIFY, That the d4Ipal Sewage Disposal System constructed (t/c or Repaired ( )
by eA,‘ cit
at
has been installed in accordance with the provisions of Article XI of The State Sanitary Code as described in the
applicnion for Disposal Works Construction Permit No dated 44.‘i r, /-
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
Bispoont agatha Tonotrortion Prrtnit
Permission i,a,-hereby granted
to Construct ( ) or Repair ( ) an Individ Sewage DisposalSyst
at No
FEE
Street
as shown on the application for Disposal Works Construction Permit No Dated
, -
DATE
FORM 1255 HOBBS a WARREN. INC.. PUBLISHERS
Board of Health