14 Septic Application & Permits CHECK OR FILL IN WHERE APPLICABLE
No FEE
THE COMMONWEALTH OF MASSACHUSETTS
BOARD OF HEALTH
OF
.Appliratiun fur Jispnsttl lBnrks Olnnstrurtinn 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
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
Disposal Trench—No. Width Total Length
Seepage Pit No Diameter Depth below inlet
Other Distribution box ( ) Dosing tank ( )
Percolation Test Results Performed by
Test Pit No. 1 minutes per inch
Test Pit No. 2 minutes per inch
Diameter Depth
Total leaching area sq. ft.
Total leaching area sq. ft.
Date
Depth of Test Pit Depth to ground water
Depth of Test Pit Depth to ground water
Description of Soil
Nature of Repairs or Alterations—Answer when applicable
•
r .
Agreement:
The undersigned agrees to install the aforedescribed Individual Sewage Disposal System in accordance with
the provi;ions 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 health.
Signed
Date
Application Approved By
Application Disapproved for the following reasons
Date
Date
Permit No Issued
Date
by
THE COMMONWEALTH OF MASSACHUSETTS
BOARD OF HEALTH
f rrtifirate of QIoutplianrr
THIS IS TO. CERTIFY, That the Individual Sewage Disposal System constructed ( ) or Repaired (/f
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 dated
THE ISSUANCE OF THIS CERTIFICATE SHALL NOT BE CONSTRUED AS A GUARANTEE THAT THE
SYSTEM WILL FUNCTION SATISFACTORY.
DATE Inspector 1
No
Permission
to Construct
at No
THE COMMONWEALTH OF MASSACHUSETTS
BOARD OF HEALTH
OF
'I
nrks QIanstrurtinn Permit
FEE
is hereby granted l
or Repair ( )an Individual Sewage Disposal System
as shown on the
Street
application for Disposal Works Construction Permit No Dated
Board of Health
DATE
FORM 1255 HOBBS & WARREN. INC.. PUBLISHERS
W7
L IN WHERE APPLIC
N
txj Nature of Repairs or Alterations—Answer when applicable
No 9 'S
THE COMMONWEALTH OF MASSACHUSETTS
BOARD OF HEALTH
OF
FEE
Appliration for Disposal Marks
Olo ttstr u u 1rrmit
Applicat ion is hereby made for a Permit to Construct ( ) or Repair ( ) an Individual
Sewage ge Disposal
System at: (j
Eovatio
1
Address
.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 Trench—No. Width Total Length Total leaching area.4 ..7..k O Osq. 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. 1
Test Pit No. 2
Description of Soil
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 health.
_Signe „net
r..L .r L✓L nr!CtP
Application Approved By
Dale
P Date
Application Disapproved for the following reasons
Permit No
Issued
� r
P,_ i Da4
Date
THE COMMONWEALTH OF MASSACHUSETTS
BOARD OF HEALTH_
OF Lien/Otrrtifiratr of Cantylinnrr
THIS IS.ZO CERTIFY, That the Individual Sewage Disposal System constructed ( ) or Repaired
by
at
has been installed in accordance with the provisions of Article tfhe State Sanitary Cod as)dgscribed yg the
application for Disposal Works Construction Permit No 7l dated._.2/ F I k 7
THE ISSUANCE OF THIS CERTIFICATE SHALL NOT BE CONSTRUED AS A GUARANTEE THAT THE
SYSTEM WILL FUNCTION SATISFACTORY.
DATE yt^-(', Y
Installer
No r
Inspector
THE COMMONWEALTH OF MASSACHUSETTS
BOARD OF HEALTH
flispxmt&- nrkiiMnnnfrnrtion 1.rrmit
Permission is hereby grant
to Construct ),,or Rosair 9._ ) an Inditjd%al Sewage Disposal System
at No
Street
as shown on the application for Disposal Works Construction PertrttiONo
DATE
FORM 1255 HOBBS & WARREN. INC.. PUBLISHERS
FEE
Yt vit
ted_;
Board of Health