43 Title 5 Application/Permits 1968 CHECK OR FILL IN WHERE APPLICABLE
No
THE COMMONWEALTH OF MASSACHUSETTS
BOARD OF HEALTH
OF
1 ppl ratinn fur 2inpusal
Fr;
Application is hereby made for a Permit to Construct
System at:
Location-Address
Owmr
Installer
Fna
arks QCnnntrurtinn hermit
or Repair (7 ) an Individual Sewage Disposal
or Lot No.
Address
Type of Building
Dwelling—No. of Bedrooms
Other—Type of Building
Other fixtures
Design Flow
Septic Tank—Liquid capacity gallons Length Width
Disposal Trench—No. Width
Seepage Pit No Diameter Depth below inlet
Other Distribution box ( ) Dosing tank ( )
Percolation Test Results Performed by
Test Pit No. 1 minutes per inch
Test Pit No. 2 minutes per inch
Address
Size Lot Sq. feet
Expansion Attic ( ) Garbage Grinder ( )
No. of persons Showers ( ) Cafeteria ( )
gallons per person per day. Total daily
Total Length
flow gallons.
Diameter Depth
Total leaching area sq. ft.
Total leaching area sq. ft.
Date
Depth of Test Pit Depth to ground water
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 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
Date
Application Approved By
Date
Application Disapproved for the following reasons
Permit No
Date
Issued
Date
THE COMMONWEALTH OF MASSACHUSETTS
BOARD OF HEALTH
OF
ftertifiratr of lIInmpliatwr
THIS IS TO CERTIFY, That the Individual Sewage Disposal System constructed ( ) or Repaired (' )
by
at
has been installed in accordance With the provisions of Article XI of The State Sanitary Code as described in the
appliction 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
Installer
THE COMMONWEALTH OF MASSACHUSETTS
BOARD OF HEALTH
OF
No ' FEE
Disposal
oe
arks Ctnnstrurtinn 1.rrmit
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
Board of Health
DATE
FORM 1255 HOBBS & WARREN. INC.. PUBLISHERS