758 Title 5 Application/Permits, 1969 THE COMMONWEALTH OF MASSACHUSETTS
BOARD OF HEALTH
OF
Fn
Applirntinu fur Jinpnsal 'fl orb @lnnstrurtinn ¶rrmit
Application is hereby made for a Permit to Construct (Vi or Repair ( ) an Individual Sewage Disposal
System at:
Location•Address /
or Lot No.
.. _...."-.._._r.:._:._.............•
Owner Address
�.“Installer Address
Type of Building Size Lot Sq. feet
Dwelling—No. of Bedrooms - ".::t 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/.& 4allons Length Width Diameter Depth
Disposal Trench—No. Width . Total Length Total leaching area sq. ft.
Seepage Pit No v Diameter r Depth below inlet f Total leaching area sq. ft
Other Distribution box ( ) Dosing tank ( )
Percolation Test Results Performed by Date
Test Pit No. I 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
'.:'="i` 11- i 'e r . .L."'...;.5?.._< ..
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 beenlssued'by the board of heals�7 ri - —
Date
Dad
Date
Application Disapproved for the following reasons'
Application Approved By
Permit No
Date
Issued
THE COMMONWEALTH OF MASSACHUSETTS
BOARD OF HEALTH
OF
drrrtifiratt of Urontottantr
--.
THIS IS TO CERTIFY, That the Individual Sewage Disposal System constructed (Vj or Repaired ( )
by
Installer
at
has been installed in accordance'with the provisions of Article XI of The State Sanitary teary Code as described in the
application for Disposal Works Construction Permit dal
it No '-
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
Uthpzmat
arks Oinnstrurtinti tirrinif
Permission is)treby granted
to Construct ( --1 or Repair ( ) an Individual Sewage Disposal System
..
at No / ' - 1
Street
as shown on the application for Disposal Works Construction Permit No ' — Dated
DATE
FORM 1255 HOBBS & WARREN. INC.. PUBLISHERS
Board of Health