70 application 1977 CHECK OR PILL IN WHERE APPLICABLE
No
THE COMMONWEALTH OF MASSACHUSETTS
FEE e
BOARD OF HEALTH
iOF p .
Applirtttinu -fur Uinlan ttl Works &nustrurtinu Permit
Application is hereby"made for a Permit to Construct ( ) or Repair (") an 1nduidual Sewage Disposal
System at:
Instal er
or Lot No.
Address
Type of Building Size Lot Sq. feet
Dwelling—No. of Bedrooms Expansion Attic ( ) Garbage Grinder ( )
Other--Type of Building No. of persona Showers ( ) — Cafeteria ( )
Other fixtures -
Design Flow gallons per person per day. Total daily flow gallons.
Septic 'f:utk—Liquid capacity gallons Length Width Dinmete- Depth -
DisposalTrench—No. Width Total Length Total leaching area sq. ft.
Seepage Pit No Diameter Depth below inlet Total leaching arer s 1-
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 mate'
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 " /t /`tr� r
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 undersigned further agrees not to place the system in
operation until a Certificate of Compliance hasbeen issued by the board of health
` t
I
Signed
r
Application Approved By
(I I P7=1. ' 7
Date
Application Disapproved for the following reasons'
Permit No ...1—i
Issued
4
Date
by
THE COMMONWEALTH OF MASSACHUSETTS
BOARD OF HEALTH
OF
&ertifirate of Templianre
THIS IS TO CERTIFY, That the Individual Sewage Disposal System constructed ( ) or Repaired ( )
at
Iias been inst:Mel in accordance with the provisions of .-Article NI 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
Permission
to Construct
at No
as shown on the
THE COMMONWEALTH OF MASSACHUSETTS
BOARD OF HEALTH
1ispnsal 3inrini Crimmtrurtinn Permit
is hereby granted - . F.-
or Repair (�/) an Individual Sewage Disposal System
•
application for Disposal Works Construction Permit tNO ' . Dated ��
DATE
FORM 1255 HOBBS & WARREN. INC.. PUBLISHERS