286 Septic Application Permit & Compliance CHECK OR FILL IN WHERE APPLICABLE
N
No....�..�%...si..t
THE COMMONWEALTH OF MASSACHUSETTS
Appitration
BOARD
OF
ALTH1
or Oiapnattl
rr
Paa_
arks Tonstructinn prrmit
Application is hereby made for a Permit to Construct ( ) or Repair
System at:
an Individual Sewage Disposal
Location-Addr
J Installer
Type of Building
Dwelling—No. of Bedrooms Expansion Attic
Other-Type of Building No. of persons
Other fixtures
Design Flow
Septic Tank—Liquid capacity
Disposal Trench—No
Address
Size Lot Sq. feet
Garbage Grinder ( )
Showers ( ) — Cafeteria ( )
gallons per person per day. Total daily flow gallons.
gallons Length Width Diameter Depth
Width Total Length Total leaching area sq. ft.
Seepage Pit No Diameter Depth below inlet
Other Distribution box ( ) Dosing tank ( )
Percolation Test Results Performed by Date.
Test Pit No. 1 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
Total leaching area sq. ft.
Description of Soil
Nature Repairs orb Nations—{tlnswe(t when gpplicabler Lv-e
Agreefient:
The undersigned agrees to install the aforedescribed Individual Sewage`tisposal System in accordance with
the provisions of TITLE 5 of the State San'tarysyy - The undersigned further agrees not to place the system in
operation until a Certificate of Compliance by b
\Sign
Application Approved By
Df�
AAZEt
Application Disapproved for the following reasons•
Permit No 37 �� l
Issued
by
THE COMMONWEALTH OF MASSACHUSETTS
BOARD OF HEALTH
OF / o
Trrtifiratt of Qlnmpliancr
THIS IS ERTIFY;.That the Individual Sewage Disposal System constructed ( ) or Repaired (
i _.. % Installer
at
has been installed in accordance with the provisions of TITLE 5 of The State Sanitary Code as de ribed in the
application for Disposal Works Construction Permit No -7 _ f dated / 1.1... ..re/
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
flinposal
rr
arks Qionatrurtinn Vrrmit
Fee
Permission is hereby granted
to Construct ( ) or Repair ( y) an Individual Sewage Disposal System
at No _
Street
as shown on the application for Disposal Works Construction Permit No Dated
Board of Health
DATE
IECK OR FILL IN WHERE APPLICABLE
No....Q.za7
THE COMMONWEALTH OF MASSACHUSETTS
FEE f/
BOARD OF HEALTH
n u 'AppRration fr flislnaal Illn n nn trtt
(� n ]ermit
Applicat ion is hereby made for a Permit to Construct ( ) or Re p air ( ) Inds idual
Sewage Disposal
System at:
b 9\4-.:fie' )
an
let
Type of Building
Dwelling—No. of Bedrooms
Other—Type of Building
Other fixtures
Design Flow gallons
Septic lank—Liquid capacity gallons
Disposal Trench—No. Width
Seepage Pit No Diameter
or Lot No.
Address
Address
Size Lot Sq. feet
Expansion Attic ( ) Garbage Grinder ( )
No. of persons Showers ( ) — Cafeteria ( )
Other Distribution box
Percolation Test Results
Test Pit No. I
Pit No. 2
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.
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
Description of Soil
Nature of Repairs or Alterations—Answer when applicable.
Agreement:
The undersigned agrees to install the aforedeseribed Individual Sewage Disposal System in accordance with
the provisions of 7ITTL:IT 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 b the board of health.
Si gre issued .,
Application Approved By
Application Disapproved for the followi
Yliv, 2es'; 19Tt
Date
reasons
by
Permit No .Q r
Date
Issued Z
Date
THE COMMONWEALTH OF MASSACHUSETTS
BOARD OF HEALTH
OF
(rirrtifiratr of fanmplianrr
THIS IS TO CERTIFY, That the Individual Sewage Disposal System coast toted ( ) or Repaired ( )
Installer
at
has been installed in accordance with the provisions of Ti?L 5 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.
DATF Inspector
by
THE COMMONWEALTH OF MASSACHUSETTS
BOARD OF HEALTH
OF
Qtrrtifirntr at Qlamplianre
THIS IS TO CERTIFY, That the Individual Sewage Disposal System constructed ( ) or Repaired
nstaller
at
has been installed in accordance with the provisions of TITIS55 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.
DATF inspector
No ' • -
THE COMMONWEALTH OF MASSACHUSETTS
BOARD OF HEALTH
OF ,
Qinpunat 'Works Qrnnntrurtinn lrrmit
Permission is hereby granted.' -
to Construct ( ) or Repair ( ) an Individual Sewage Disposal System
at No
Street
shown on the application for Disposal Works Construction Permit No Dated
Board of Health
DATE
FORM 1255 HOBBS & WARREN, INC., PUBLISHERS