472 Septic Application & Permits ERE APPLICABLE
ECK OR FILL IN
No..l
THE COMMONWEALTH OF MASSACHUSETTS
BOARD OF HEALTH
OF Application for Motional� wk�(llnn trurtinn f ermi# /
Application is hereby made for a Permit to Construct (k ) or Repair ( ) an Individual Sewage Disptlsai
FEE
System at:
or Lot No.
Type of Building
Dwelling—No. of Bedrooms ' Expansion Attic
Other—Type of Building No. of persons
Other fixtures
Design Flow ga lons per person per day. Total daily flow.. gallons.
Septic Tank—Liquid capacitya�dgallons J.ength Width Diameter
Disposal Trench—No Width@Za Total Length sae Total leaching area
Seepage Pit No Diameter Depth below inlet
Other Distribution hox ( ) Dosing tank ( )
Percolation Test Results Performed by
Test Pit No. ] minutes per inch Depth of Test Pit
Test Pit No. 2 minutes per inch Depth of Test Pit
Address
Address
Size Lot Sq. feet
Garbage Grinder ( )
Showers ( ) — Cafeteria ( )
Depth
a 0 sq. ft.
Total leaching area sq. ft.
Date
Depth to ground water
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 Sanita Code— The yandersigned further agrees not to place the system in
operation until a Certificate of Compliance has belt issued by
er-�iA".Vl
Application Approved By
2A Sr
Application Disapproved for the following reasons
Permit No /
Issued
by
at
has been installed in accordance with the provisions of Artic)e(I of The State Sanitary C as described in the
application for Disposal Works Construction Permit No f dated_. 4‘.._./QI�.i
THE ISSUANCE OF THIS CERTIFICATE SHALL NOT BE CONSTRUED AS A U RANTEE THAT THE
SYSTEM t•{VILLUIN�CjIOPj�ATISFACTORY. �- l 4 y`
DATE 'QQ f6,�� JJi //i 1 S Inspecmr ✓.y{ tR°•
THE COMMONWEALTH OF MASSACHUSETTS
BOARD
el OF
Qirrtifiratr of en liana �/
THIS I TO ER T-14173',A1'hat t¢e Individual Sewage Disposal System constructed r ) or Repaired ( )
OF HEALTH
Installer
No)3/
THE COMMONWEALTH OF MASSACHUSETTS
BOARD OF HEALTH
OF Qiupnnal Jd u ( pit rntGtiuu ¶rrmit
Permissioq t hereby granted
onstru (r or Pep 'r (.
to C 7 1 2 �t an I ivid
at No 1 %-Q"�i7
FEE
age Disposal System
street
as shown on the application for Disposal Works Construed° unit No.inylia ._. Datest_.�
DATE"
FORM 1255 HO8B5 & WARREN. INC.. PUBLISHERS
Boars or eaL{h
CHECK OR FILL IN WHERE APPLICABLE
No I � Eau
THE COMMONWEALTH OF MASSACHUSETTS
BOARD OF HEALTH
t iL. OF .7 "`_f"7+rN
Appltrntisn fur lalapu nt h irks Cnnttstru�rfinn 1drrmit
lion is hereby for a Permit to Construct ( ) or Repair �✓) an Individual
Application y age Disposal
System at:
Sewage
' ) C
Locat
Installer
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 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.
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. I
Test Pit No. 2
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 NI of the State Sanitary Code—The signed further agrees not to place the system in
operation until a Certificate of Compliance has been iss by a ar of h lth.
Application Approved By
540
{ Date
Application Disapproved for the following reasons'
Permit No 1
Issued z "
4r Ju re
If Date
THE COMMONWEALTH OF MASSACHUSETTS
BOARD OF HEALTH
OF ljeri'eS114"?6'1
Tertiftrate of Compliance
THIS IS TO CE$TIFY. That [hel l
by
at iher e.v cJ and
has been installed in accordance with the provisions of Article NI of The State Sanitary C as descrjbed� Ftlbe
application for Disposal Works Construction Permit No / e4- dated ty1
THE ISSUANCE OF THIS CERTIFICATE SHALL NOT BE CONSTRUED AS A GUARANTEE THAT THE
SYSTEM W FUNCTION SATISFACTORY.
-r r ? 1 4 6 6 Inspector ;� ' g �_ n n
al Sewage Disposal System constructed ( ) or Repaired ( " )
THE COMMONWEALTH OF MASSACHUSETTS
BOARD F HEALTH
... vC
OF ■f sl Oster,
No FEE
Biannual j nrt�s Co /ruffian Permit
Permission is hereby grant t r f?'
to Construct ( ) or Repair A ) at; Indiv dual age Disposal System
at No
Street
as shown on the application for Disposal Works Construction Permit
DATE
FORM 1235 HOBBS Et WARREN. INC.. PUBLISHERS
11, 4
CHECK OR FILL IN WHERE APPLICABLE
PEE
THE COMMONWEALTH OF MASSACHUSETTS
BOARD OF HEALTH
OF f,51,1
Application foie linpnnttl 1! Orlon tnnnmtctinn j rrmii
Application is hereby made for a Permit to Construct ( ) or Repair ( an Individual Sewage Disposal
System at: _
.._tff2..1L1=
Location.Address or Lot No.
Owner
Address
per Installer V j_•:.r 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„.......1.gallons Length Width Diameter Depth
Disposal Trench—No. Width Total Length Total leaching area " J..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.y.
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 lrd of h Ith.
Signed - `/
Application Approved By
, I
Application Disapproved for the following reasons
4
Date f
V Date
Date
Permit No ? Issued
Date
THE COMMONWEALTH OF MASSACHUSETTS
BOARD OF HEALTH
OF V4itPLU
. atiftat& of Qlntnfilianrr
TFIS&-Z,S TO CIRTIFY, Tat/the In 'victual Sewage Disposal System constructed ( ) or Repaired (%e<-
by
at A i9.4. i _
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 (,(,u,.Q,.....1.5 % .x.: Inspector..,.G.
.a
...44Cet. at
No_,.:.._..j
THE COMMONWEALTH OF MASSACHUSETTS
BOARD OF HEALTH
OF AYj
u
Disposal
ili
arks Qtnnstrnrtionst it
Permission is hereby granted.
Construct ( ) or Repair (j�adindivid
at No
age Disposal Sys
FEE
Street
as shown on the application for Disposal Works Construction Permit No .^ Dated - f
Board of Health
DATE
FORM 1255 HOBBS 8 WARREN. INC.. PUBLISHERS