31 Title 5 Application/Permits 1971 CHECK OR FILL IN WHERE APPLICABLE
No
FEES red
THE COMMONWEALTH OF MASSACHUSETTS
H
�,GG�Y j* OF F
%ppliratinn for Ruyan' nrko &innntrurtinn Permit
Application is hereby made for a Permit to Construct ( ) or Repair (P ) an Individual Sewage Disposal
System at:
or Lot No.
Address
Address
Type of Building
Size Lot Sq. feet
Dwelling g—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
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
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 farther agrees not to place the system in
operation until a Certificate of Compliance has been issued by the board of health.
Signed.L 62:{.vS1.:tC.�_r & :21(6
Application Approved By -
Application Disapproved for the following reasons
Permit No
Issued .a+.?.-f
THE COMMONWEALTH OF MASSACHUSETTS
BOARD OF HEALTH
Certificate of Otnn4ttanre
THISf4S TO CERTIFY, That,the Individual Sewage Disposal System constructed ( ) or Repaired
by C _ T Installer
at .'. 1.,.. } u,,....:- .ts«r...:.
has been installed in accdtda ce with the provisions of Article XI of The State Sanitary Code as described in the
�
application for Disposal Works Construction Permit No •/ :it/ dated , ;1�.::..r ' d .4.7
THE ISSUANCE OF THIS CERTIFICATE SHALL NOT BE CONSTRUED AS A GUARANTEE THAT THE
SYSTEM WILL FUNCTION SATISFACTORY.
i
DATE 1[ w...2.4 .4:74 Inspector..., ._., ,' t,1,-
it
Na-...
THE COMMONWEALTH OF MASSACHUSETTS
WARD OF HEALTH
OF
flin}Tnsat
arks Qlnnstrnrttnn Permit
Permission is hereby granted,...'
to Construct ( ) or Repair V�) an Individu, Sewage Disposal System
at No : f r/., ........f}.- ;;:.i....C.. Street
shown on the application for bispMal Works Construction Permit No Dated
DATE
FORM 1253 HOBBS & WARREN. INC.. PUBLISHERS
Board of Hearth