311 Application & Permit 1967 CHECK OR FILL IN WHERE APPLICABLE
THE COMMONWEALTH OF MASSACHUSETTS
BOARD OF HEALTH
OF
1 ppliratinn fur /i pi:mai
be
Application is hereby made for a Permit to Construct
System at:
a!1
Lpnrion-Address
U
Owner {
y!N� .... t ...L•K.v/'i' I
Instal
Type of Building
Dwelling—No. of Bedrooms
Other—Type of Building
Other fixtures
Design Flow
Septic Tank—Liquid capacity
Disposal Trench—No
Seepage Pit No
Other Distribution box
Percolation Test Results
Test Pit No. 1
Test Pit No. 2
arks (IInnstr
Fns
it jermit
or Repair ( ) an Individual Sewage Disposal
or Lot No.
Address
Address
Size Lot Sq. feet
Expansion Attic ( ) Garbage Grinder ( )
Showers ( ) — Cafeteria ( )
No. of persons
gallons per person per day. Total daily flow gallons.
gallons Length Width Diameter Depth
Total Length Total leaching area sq. ft.
Depth below inlet Total leaching area sq. ft.
Dosing tank ( )
Date
Depth of Test Pit Depth to ground water
Depth of Test Pit Depth to ground water
Width
Diameter
Description of Soil
Performed by
minutes per inch
minutes per inch
Nature of Repairs or Alterations—Answer when
(�. b.1.1.6 .
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 health
Signed
Application Approved By ;.1 "- - .eL •
Application Disapproved for the following reasons
icable_ 3.ttSzof......:.
Permit No Issued e,
Date
by
THE COMMONWEALTH OF MASSACHUSETTS
BOARD OF HEALTH
OF
Qtntifirate of ( ompliana
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
applic tti'm 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
THE COMMONWEALTH OF MASSACHUSETTS
BOARD OF HEALTH
OF :G1b` _ nGG< a.. . .. .
No
fisponal ,rr arks Olunstrurtion hermit
Permission is hereby granted " `' a ` G, _
an Individual Sewage Disposal ys
to Construct ( ) or Repair ( '5 System
No
Street
-...:.,_.._....._.. et....
so-
as shown on the application for Disposal Works Construction Permit No Dated
DATE 4"/
/
FORM 1255 HOBBS & WARREN, INC., PUBLISHERS
FEE
Board of Health