29 Application & Permit 1975 ra 6 es
THE COMMONWEALTH OF MASSACHUSETTS
OARD OF HEALTH
oF �, '
hpnntt1 Work!'
urtinn tint-nit
.gpplirutinu far
Application is hereby made for a Permit to Construct ( ) or Repair (11<in Individual Sewage Disposal
FEE /1..L
System at:
or Lot No.
Address
Address
Size Lot Sq. feet
Type of Building e Grinder ( )
Dwelling—No. of Bedrooms Expansion Attic ( ) Garbage
No.Nf
Othec —Type of Building of pe'ssp1' Showers ( ) — Cafeteria ( )
Other fixtures
Design Flow gallons per person per day.
Septic Tank—Liquid capanty gallons Length VA'idtli
Disposal Trench—No. Width Total Length
Seepage Pit No Diameter Depth below inlet
Other Distribution box ( ) Dosing tank ( )
Date
Percolation Test Results minutes per by Depth to ground Ovate•
Test Pit No. 1 minutes per inch Depth of Test Pit I
minutes per inch Depth of Test 1'it Depth to ground water -.-
Test Pit No. 2 p
Total daily flow .gallon'.
Diameter Depth_
Total leaching area sq. ft.
Total leaching are' sq. f:.
Description of Soil
_. _ . . _ . n when - n ( to-e
Nature of Repairs or Alterations—Answer en apphcable_�fh{�/'G=-
Agreement:
The undersigned agrees to install the aforedescribed Individual Sewage Disposal System in accordance with
the provisions of Article NI of the State Sanitary Code—The uncle signed further agrees not to place the system in
operation until a Certificate of Compliance has been issued by the ho. of health. ,}.,
Ir_�-e__
Application Approved By
Application Disapproved for the following reasons'
2.1475
m«
Permit No a
Oat
Issued At • S .1 Ili—
Date
by
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
(Eradicate of (iCnm}tlianre
THIS IS TO CERTIFY, That the Individual Sewage Disposal System constructed ( ) or Repaired
Installer
No
C3
THE COMMONWEALTH OF MASSACHUSETTS
BOARD OF HEALTH
J , .TX. I
OF
Biopooalni nrko T2n otrttiot Wand
Permission is hereby granted
to Construct ( ) or Repair ( ) an 1Individual Sewage Disposal SystEr
at No
Stirrer
as shown on the application for Disposal Works Construction_Permit No patecl
Board of Health
DATE
FORM 1255 HOBOS P. WARREN. INC- PUBLISHERS