565 Sepic Application & Permit 1989 • No
CHECK OR FILL IN WHERE APPLICABLE
THE COMMONWEALTH OF MASSACHUSETTS
BOARD OF HEALTH
OF
Appliration for Binomial
Fla
arks afonstrurtion ¥erncit
Application is hereby made for a Permit to Construct ( ) or Repair (/) an Individual Sewage Disposal
System at:
Location-Address
or Lot No
Owner 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 How 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. I 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 TITLE 5 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
Date
Application Approved By
Date
Application Disapproved for the following reasons'
Permit No Issued. _
Date
THE COMMONWEALTH OF MASSACHUSETTS
BOARD OF. HEALT
OF
Trrtifiratr of Tomplixarr
TO // ' F pit the Ind?bidt Se vage Disposal System constructed ( ) or Repaired
at
has been installed in accordance with the provisions of TITLE 5 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
Permission
to Construct
at No
THE COMMONWEALTH OF MASSACHUSETTS
BOARD .OF HEALTH
OF
Tinpnsa1
f;li
litho Ql nnwtrnutiuu ljrrmff
FEE
is hereby granted
or Repair (> ) an Individual Sewage Disposal System
as shown on the
Street
application for Disposal Works Construction Permit No Dated
Board of Health
DATE
FORM 1255 A. M. SULKIN, IN G.. BOSTON
1