94 Title 5 Application/Permits 1975 CHECK OR FILL IN WHERE APPLICABLE
- No4ry
•
THE COMMONWEALTH OF MASSACHUSETTS
BOARD OF HEALTH
OF
Applintaint fur Bizpozat
F 3# dl
van Tonstrurtinit tirrmit
Application is hereby made for a Permit to Construct ( ) or Repair ( ) an Individual Sewage Disposal
System at:
4
•ratiat•c4P,
satZti dd=C2
°07-LLAI2
Installer
Type of Building
Dwelling—No. of Bedrooms
Other—Type of Building
Other fixtures
Design Flow gallons
Septic Tank—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. 1
Test Pit No. 2
per person per day. Total daily flow gallon,.
Length Width Del nh
Total I ength 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 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 bee sued by the board of health.
, .pt-sriol 1 Pf Xs--
Application Disapproved for the following reasons•
Application Approved By
Signe
7, lfPermit No. e Issued -0S
D
by
THE COMMONWEALTH OF MASSACHUSETTS
BOARD OF HEALTH
OF
@Iertiftrate of (aumplianrr
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 . . .. -.. .. . .
Uinpnsttl lurks Lnnstrurtinn 1rrmit
FEE
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