502 Application & Permit 1970 CHECK OR FILL IN WHERE APPLICABLE
No
THE COMMONWEALTH OF MASSACHUSETTS
BOARD OF HEALTH
OF
Application for Oispnsttl
rr
FEE
orb Q2nnotrurtion Orrmit
Application is hereby made for a Permit to Construct ( ) or Repair (, ) an Individual Sewage Disposal
System at:
Location.Address
Owner
or Int No
Address
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
Seepage Pit No
Other Distribution box
Percolation Test Results
Test Pit No. 1
Test Pit No. 2
Address
Size Lot Sq. feet
Garbage Grinder ( )
Showers ( ) — Cafeteria ( )
gallons per person per day. Total daily flow
gallons Length Width
Width Total Length
Diameter Depth below inlet
Dosing tank ( )
Performed by
minutes per inch Depth of Test Pit
minutes per inch Depth of Test Pit
gallons.
Diameter Depth
Total leaching area sq. ft.
Total leaching area sq. ft.
Date
Depth to ground water
Depth to ground water
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 heglth.
Application Approved By
Signed *
Application Disapproved for the following reasons'
F'i!b"t'`st
Date
Date
Date
•
senegiccial
Permit No Issued
Date
by
THE COMMONWEALTH OF MASSACHUSETTS
BOARD OF HEALTH
OF
Utrrtifiratr of atou plianrt
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
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
THE COMMONWEALTH OF MASSACHUSETTS
BOARD OF HEALTH
OF
No FEE
Elwood i,arks (Construction jrrmit
Permission is hereby granted
to Construct ( ) or Repair ( : ) an Individual Sewage Disposal System
at No
Street
as shown on the application for Disposal Works Construction Permit No Dated
Hoard of Health
DATE
FORM 1255 MOBS? Y WARREN. INC.. PUBLISHERS