279 Septic Application Permit & Compliance CHECK OR FILL IN WHERE APPLICABLE
No..0S
THE COMMONWEALTH OF MASSACHUSETTS
Fag
BOARD OF HEALTH
J .,M
Appl ration for Binomial arks hlnns#rur9ion Permit
Application is hereby made for a Permit to Construct ( ) or Repair
System at:
L4anon•Address
G (�
an Individual Sewage Disposal
or Lot No.
Address
oInstaller 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. 1
Test Pit No. 2
Description of Soil
Vat of Repairs or teyations—Answer whe¢ applicabl - 'r nu
._ ➢.Q 'LSE Sault ' (gcrc._R ltr:...l::st�=fl.. ... .. ,�.t,Ld
Agreement: u
The undersigned agrees to install the aforedescribed Individual Sewage Disposal System in accordance with
the pro 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 ben issued by the brd bf heal
t j .. a
Signed
J /fed a%!p$.l 6+( .z.. .4e
Application Approved By.....
.......__`..„:.
Da
Application Disapproved for the following reasons•
Permit No....r_.�.�1 Issued_ -
Date
Dame
THE COMMONWEALTH OF MASSACHUSETTS
BOARD OF HEALTH
le`
Q ertif ratr of Tontolianrr
THIS IS TO CFyRTIFZ.,That the Individual Sewage Disposal System constructed ( or Repaired ( )
by
7 Installer
at ,y i✓-vi .tes. << }"
has been installed in accordance With the provisions of Article XI of The State Sanitary Code as described in the
m
apphm
cctn for Disposal Works Construction .zstimr Permit No . .:f dated
THE ISSUANCE OF THIS CERTIFICATE SHALL NOT BE CONSTRUED AS A GUARANTEE THAT THE
SYSTEM WILL FUNCTION SATISFACTORY.
DATE fL:.:_.1..... ..... t 7 Inspector
THE COMMONWEALTH OF MASSACHUSETTS
BOARD OF HEALTH
No .(...
Binpnsnl "'Portia consirurtinn jfr nit
FEE
Permission is hereby granted„,._._..._'::-t..i..4i=:to Construct ( ) or Repair ( k) an Fndividual.5ewage Disposal System
at No < — ..-=c(fp `e"'°L.
j Street
as shown on the application for Disposal Works Construction Permit No Dated
� ( a ” Bozrd of Health()
DATE (Lb'm d...://.✓✓ -
FORM 1255 H&BBS & WARREN, INC.. PUBLISHERS