218 Septic Application & Permit 1967 •
CHECK OR FILL IN WHERE APPLICABLE
No
THE COMMONWEALTH OF MASSACHUSETTS
BOARD OF HEALTH
„--- /- ,
OF
apptirtttinn for lispo,ittl i arks «Lunntrurtinn 1 rrmit
FEE
Application is hereby made for a Permit to Construct (k5 or Repair ( ) an Individual Sewage Disposal
System at: ,
a�$
Lotion
'.4 J. .ocatlo
■f .1..r,`,..._. A_.'lLrMO /Own r 1N
a Installer Address F`
Type of Building Size Lot Sq. feet
Dwelling—No. of Bedrooms mtF��jj- Expansion Attic ( ) Garbage Grinder ( )
Other—Type of Building No. of persons Showers ( ) — Cafeteria ( )
Other fixtures
Design Flow 5 gallons per person per day. Total daily flow 1 '' 4 gallons.
Septic Tank—Liquid capacityL .)_.gallon 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 ‘2.2— sq. ft.
Other Distribution box ( ) Dosing tank ( )
Percolation Test Results Performed by Date
Test Pit No. I._.LV minutes per inch Depth of Test Pit Depth to ground water
Test Pit No. 2 minutes per inch Depth of Test Pit Depth to ground water
or Let No.
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 health.
Signed
Application Approved By * ' .Li.i t 7,:-
l
Date
Application Disapproved for the following reasons'
Permit No . - Issued
Date
Date
THE COMMONWEALTH OF MASSACHUSETTS
BOARD OF HEALTH
OF
tIIrrtifitatr at iltnntplittnrr
THIS IS TO CERTIFY, That the Individual Sewage Disposal System constructed VA or Repaired ( )
by
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 dated -
THE ISSUANCE OF THIS CERTIFICATE SHALL NOT BE CONSTRUED AS A GUARANTEE THAT THE
SYSTEM WILL FUNCTION SATISFACTORY.
DATE — Inspector
THE COMMONWEALTH OF MASSACHUSETTS
BOARD OF HEALTH
OF ,
flispnnal rr;inks Qtnnstrnrtinn prrmit
Permission jihereby granted
to Construct (V) or Repair ( ) an.Sndividual Sewage Disgosalf System
at No
FEE
street
as shown on the application for Disposal Works Construction Permit No Dated
DATE
FORM 125E HOBBS & WARREN, IN C., PUBLISHERS
Board of Health