248 Septic Application & Permit 1972 CHECK OR FILL IN WHERE APPLICABLE
No...1 (,),I
THE COMMONWEALTH OF MASSACHUSETTS
BOARD OF HEALTH
OF 7�-Ca�
Application for latopotial rr nrits unntrnrftun Nermif
Application is hereby made for a Permit to Construct (• ) or Repair ( ) an Individual Sewage Disposal
System at: O l
9 Pe ,
- n Coati° Ad / or Lot No.
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 t gallons per person per day. Total daily flow gallons.
Septic Tank—Liquid capacityja4allons Length Width Diameter Depth
Disposal Trench No Width Total Length Total leaching area ..1 W..Q..sq. ft.
Seepage Pit No Diameter Depth below inlet Total leaching area sq. ft.
Other Distribution box ( ) Dosing tank ( )
Percolation Test Results Performed by Date
Test Pit No. 1 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
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.
Signe
r ye
Application Approved By .<.$ 2.. . .:L ,....�!/._. fln .
Application Disapproved for Me following reasons
mte
Permit No...,T�Or
Issued
by
THE COMMONWEALTH OF MASSACHUSETTS
BOARD OF HEALTH
OF
(rrtifiratr of Tamplianrr
THIS IS TO CERTIFY, That the Individual Sewage Disposal System constructed ( ) or Repaired ( )
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
No.5/5
THE COMMONWEALTH OF MASSACHUSETTS
BOARD OF HEALTH
OF tittltb43
Uinpnnat arks Olz nstrnrtian lrrmit
Permission is ereby granted h.HsiL...i
to Construct (L or J e(rair ( ),Ian Tn-dividuaL-Sewage Disposal System
at No 1{..,k 6.4i
FEE/,3. ..
street
as shown on the application for Disposal Works Construction Permit No.,j._G.S Dated_at4�Q �C-...L1.r.-1?
DATE
FORM 1255 HOBBS & WARREN
INC.. PUBLISHERS
B�:o "th;