219 Septic Application & Permit 1966 CHECK OR FILL IN WHERE APPLICABLE
No
THE COMMONWEALTH OF MASSACHUSETTS
BOARD QF H ALTH
OF (Art-i1APir4•"&
Appliratiun fur %Jispulin(
Fil
Fax
arks Tountrurtjnn lrrmit
Application is hereby made for a Permit to Construct ( ) or Repair p (Plc Individual Sewage Disposal
System at:
La 2.7ddre _ (;� or Lot No.
Owner= Address
1u taller Address
Type of Building
Dwelling— No. of Bedrooms
Other—Type of Building
Other fixtures
Design Flow
Septic Tank—Liquid capacity
Disposal Trench— No.
Seepage Pit No
Other Distribution box (
Percolation Test Results
Test Pit No. I
Test Pit No. 2
Size Lot Sq. feet
Expansion Attic ( ) Garbage Grinder ( )
No. of persons Showers ( ) — Cafeteria ( )
gallons per person per day. Total daily flow gallons.
gallons Length Width Diameter Depth
Width Total Length Total leaching area sq. ft.
Diameter t Total leaching area sq. ft.
Depth below He
Dosing tank ( )
Performed by
minutes per inch
minutes per inch
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
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 tad signed further agrees not to place the system in
operation until a Certificate of Compliances issued bv tShe rd of ealth.
Signed-.
Application Approved By
Application Disapproved for the following reasons.
Permit Nti-N
Issued
Da‘ // r
/ V/ �
Date
Date
b
THE COMMONWEALTH OF MASSACHUSETTS
BOARD OF HEALTH
OF
Tertifirttte of ( nmplianre
THIS IS TO CERTIFY, That the Individual Sewage Disposal System constructed
Installer
or Repaired
)
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 Inspoctor
THE COMMONWEALTH OF MASSACHUSETTS
BOARD OF HEALTH
--k". OF %11.:^t-ij/4 i-.ry �&
His}rnstt�, su Ks Oanstrurtinu Permit
%1 k
Permission is hereby grant li - � C^I
to Construct ( ) prRepay ( ) an Irldividual Sewage Disposal System
at No cs1 1 ( ^ i/7. ,:G1 ^h-- 1-1,.re
FEE
Street
as shown on the application for Disposal Works Construction Pet jit No 721-5_ Dated ,111/1.1
Board of Health 0
DATE
FORM 1255 HOBBS & WARREN. INC.. PUBLISHERS