248 Septic Application Permit & Compliance CHECK OR FILL IN WHERE APPLICABLE
No i3
THE COMMONWEALTH OF MASSACHUSETTS
BOARD OF HEALTH
�F OF /y,zSY-elt-rr+nrer
Application fur %in.pnnal rl urns(ltuni trurtinu hermit
Application is hereby made for a Permit to Constru
System at
1.
m:A addr���
0
-i
or Repair ( ) an Individual Sewage Disposal
or Lot No.
Address.
1nrtaTIcr 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 I of- v allons 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 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 board of heajth.
-tS'ig4ed f
_ { 4/.7 vI
Application Approved By
Date
Application Disapproved for the following reasons
Permit No 13 0
Date
Issued
Date
by
at
has been installed in accordance with the provisions of Article x of The State Sanitary Code as described in the
application for Disposal Works Construction Permit No U dated
THE ISSUANCE OF THIS CERTIFICATE SHALL NOT BE CONSTRUED AS A GUARANTEE THAT THE
SYSTEM{�WIL} FUNCTION SATISFACTORY. ,'p_ _ J-
DATE. �(",F"4, Ye 9` `S Inspector 1 iO� 1ne
THE COMMONWEALTH OF MASSACHUSETTS
BOARD OF
OF
HEALTH
rrtifirttfr of To liana
THIS (A !T CER%7P I ai the Individual Sewage Disposal System constructed ( ) or Repaired ( )
a 4 F ,iala, -a--
Installer
No 130
THE COMMONWEALTH OF MASSACHUSETTS
yy BOARD /O,F�(HEALTH
flispn nl jnrks�@I
Permission 9>httrehy granted
to Construct.
C
at No
r urtinn tirrmit
FEr
.ap Individual Sewage Disposal System
seed
as shown on the application for Disposal Works Construction Pern
DATE
FORM 1255 HOBBS & WARREN, INC.. PUBLISHERS
0, /30 Dat,ed >41-9,“
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