323 Septic Aplication & Permit 1987 CHECK OR FILL IN WHERE APPLICABLE
No
THE COMMONWEALTH OF MASSACHUSETTS
BOARD OF HEALTH
t r1r OFMNo&THAM Pi
Application for 33isposttl i arks Tonstrurtiun rrmit
Application is hereby made for a Permit to Construct ( ) or Repair (✓) an Individual Sewage Disposal
System at: _�E , r,.
J i
Location.Address.
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 Diameter Depth
Disposal Trench—No. Width Total Length Total leaching area 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
t fr
Nature .∎ .,„^ . or Alterations-Answer when a lftajile
pp
,Q,vrM =d/:. V Cif —,'_ ° Af lS _ t Cf
Agreement:
The undersigned agrees to install the aforedescribed Individual Sewage Disposal System in accordance with
the provisions of TITLE 5 of the State Sanitary Code—The undersigned further agrees not to place the system in
operation until a Certificate of Compliance e been issued by the board of health. /
✓Sincgned
Date
Date
Application Disapproved for the following reasons•
Application Approved By
Permit No
Issued
by
at
THE COMMONWEALTH OF MASSACHUSETTS
BOARD OF HEALTH
7v OF N N
Ilirrtifiratr of fitumplianrr
THIS IS TO CE FY That the •.: idual/Sewage Disposal System constructed ( ) or Repaired (v)
/7),/ ;we-
Cr
has been installed in accordance with the provisions of TITLE /g,of The State Sanitary Cod a d 'bed in the
application for Disposal Works Construction Permit No /7 '�� dated--3/LV6�
THE ISSUANCE OF THIS CERTIFICATE SHALL NOT BE CONSTRUED AS A GUARANTEE THAT THE
SYSTEM WILL FUt4CTION SATISFACTORY.
DATE a !? /277 Inspector
No
THE COMMONWEALTH OF MASSACHUSETTS
BOARD OF HEALTH
° pp NrlH lH.vM u'
Disposal J7yJ�turks �txuwtrurtiun Drrt it
Permission is hereby granted !T"
to Construct ( Sr Reppir ( y)^an.IndividualrSewage Disposal-System
at No
Street
as shown on the application for Disposal Works Construction Permit No ;- Dated
Fait
//
• I
DATE
FORM 1255 A. M. SULKIN,INt. BOSTON
Board of Health