604 Septic Application & Permits by
THE COMMONWEALTH OF MASSACHUSETTS
BOARD OF HEALTH
OF
Trrtifiratt of ftfnmplianrt
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.
THE COMMONWEALTH OF MASSACHUSETTS
BOARD OF HEALTH
OF
%tlnnal cii nrkn Ql nntrurtinn jtratit
Permission is hereby granted
to Construct ( ) or Repair (/) an Individual Sewage Disposal System
at No
FEE
Street
as shown on the application for Disposal Works Construction Permit No - Dated
DATE
FORM 1255 HOBBS 8 WARREN. INC_ PUBLISHERS
Board of Health
CHECK OR FILL IN WHERE APPLICABLE
No
Fez
THE COMMONWEALTH OF MASSACHUSETTS
BOARD OF HEALTH
OF
Application for Disposal clerks hlnnstrurtinn Daunt
Application is hereby made for a Permit to Construct ( ) or Repair (' ) an Individual Sewage Disposal
System at: 44
ti
Laatiov,rl, Best
Owner
Installer
Type of Building
Dwelling—No. of Bedrooms
Other—Type of Building
Other fixtures
Design Flow gallons
Septic Tank—Liquid capacity gallons
Disposal Trench—No \Vidth
Seepage Pit No Diameter
Other Distribution box ( ) Dosin
Percolation Test Results Performed by
Test Pit No. 1 minutes per inch
Test Pit No. 2 minutes per inch
or Lot No.
Address
Expansion Attic
No. of persons
Address
Size Lot Sq. feet
Garbage Grinder ( )
Showers ( ) — Cafeteria ( )
per person per day. Total daily flow gallons.
Length Width Diameter Depth
Total Length Total leaching area sq. ft.
Depth below inlet Total leaching area sq. ft.
g tank ( )
Description of Soil
Date
Depth of Test Pit Depth to ground water
Depth of Test Pit Depth to ground water
Nature of Repairs or Alterations—Answer when applicable..._::
i
: " I "...,a
Agreement: b
The undersigned agrees to install the aforedescribed Indio al
the provisions of Article XI of the State Sanitary Code—The unders
operation until a Certificate of Compliance has been issued by tbs?oard
/
ti d
Signed
Application Approved By
Sewage Disposal System in accordance with
ed further agrees not to place the system in
of heal
Application Disapproved for the following reasons'
Permit No _
Issued.
Date
Date
Date
Date
CHECK OR FILL IN WHERE APPLICABLE
No /i -
Fes .13
THE COMMONWEALTH OF MASSACHUSETTS
BOARD OF HEALTH
-ai
,`� OF , . . .r�,.G-,:: .
Appliratinu fur Dismal 333urk Cnuantrurtinn Permit
Application is hereby made for a Permit to Construct (F—) or Repair ( ) an Individual Sewage Disposal
System/a(:
Locattat ddr
or Lot No.
Address
Type of Building
Dwelling—No. of Bedrooms f h Expansion Attic
Other—Type of Building No. of persons
Other fixtures
Design Flow
Septic Tank—Liquid capacity/ 4
Disposal Trench—No
Seepage Pit No
Other Distribution box
Percolation Test Results
Test Pit No. 1
Test Pit No. 2
Description of Soil
)Ii
Address
Size Lot � w� fm
Garbage Grinder ( )
Showers ( ) — Cafeteria ( )
gallons per person per day. Total daily flow gallons.
Width Diameter Depth
Total leaching area sq. ft.
Total leaching area sq. ft.
gallons Length
Width Total Length
Diameter o Depth below inlet
Dosing tank ( )
Performed by
minutes per inch Depth of Test Pit
minutes per inch Depth of Test Pit
Date
Depth to ground water
Depth to ground water
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 l'ITLB 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 borard of health.
Signed f :f/
/v._ 1Y
Application Approved By
Application Disapproved for the following reasons-
I
7Y
Date
Permit No
_/J
Date
Issued
Date
tai (..a -1Lu/ jets" gar4Yv tPl w�l
6�T/CSI �riTHE�OOMM��NWEALTH OF MASSACHUSEJT S _ O"O i
® � �
BOARD OF HEALTH Ale- c(`-v' -°�C
OF
Trrtifiratr of Tumplittttrt
THIS iY p CERTIFY, That the Individual Sewage Disposal S5ysttnnanat ucted ( ) or Repaired ( )
by \�``___ i 1
at
has been installed in accordance with the pro s of T`T 5 of Th/� State Sanitary Code as described in the
application for Disposal Works Constr on Permit No-- / /'T dated
THE ISSUANCE OF THI ERTIFICATE SHALL NOT B ,TRUED AS A GUARANTEE THAT THE
SYSTEM WILL FUNCTI SATISFACTORY.
DATE Inspector
Inspector
No
$1- j /
THE COMMONWEALTH OF MASSACHUSETTS
BOARD OF HEALTH
OF
flhpnsttl Moritz Cnnutrttrtinn ermit
Permission is hereby granted
to Construct (IX or Repair ( )_an Individual Sewfryge`Disposal Sypem E,
at No as shown on the application for Disposal Works Construction Permit No .< ateden.:(.4 (r-
>r
DATE 7 t
FORM 1255 HOBBS
ARISEN. INC_ PUBLISHERS
Street ,
card of H