545 Application & Permit 1969 So Fez
THE COMMONWEALTH OF MASSACHUSETTS
BOARD OF HEALTH
OF
Application fur Binomial
li1,
Application is hereby made for a Permit to Construct
System at:
(
........._'' L._::._
- ion-Address
..._...... .... 1....•11..._.._!vr..�.6.:._
Owner
Installer
urku l2tunntrurtiun ljermit
or Repair (i/an Individual Sewage Disposal
or Lot No.
Address
Address
Type of Building Size Lot Sq. feet
Dwelling—No. of Bedrooms Expansion Attic ( ) Garbage Grinder ( )
Other—Type of Building No. of persons Showers ( ) — Cafeteria ( )
Other fixtures
)esign Flow gallons per person per day. Total daily flow gallons.
Septic Tank—Liquid capacity gallons Length Width Diameter Depth
)isposal Trench—No. Width Total Length
Seepage Pit No Diameter Depth below inlet
)ther Distribution box ( ) Dosing tank ( )
'ercolation Test Results Performed by Data
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
Total leaching area sq. ft.
Total leaching area sq. ft.
)escription of Soil
Mature of Repairs or Alterations—Answer when applicable
Agreement:
The undersigned agrees to install the aforedescribed Individual Sewage Disposal System in accordance with
he provisions of Article XI of the State Sanitary Code—The undersigned further agrees not to place the system in
>peration until a Certificate of Compliance has been issued by the board of health.
Signed —
Date
Date
Date
Permit No..._. Issued
Application Approved By
Application Disapproved for the following reasons•
V
THE COMMONWEALTH OF MASSACHUSETTS
BOARD OF HEALTH
OF
Qtrrtifiratr of fllntitplistur
THIS IS TO CERTIFY, That the Individual Sewage Disposal System constructed ( ) or Repaired ( )
Installer
A
Is been installed in accordance with the pfovisions of Article XI of The State Sanitary Code as described in the
>plication for Disposal Works Construction Permit No - dated - -
THE ISSUANCE OF THIS CERTIFICATE SHALL NOT BE CONSTRUED AS A GUARANTEE THAT THE
YSTEM WILL FUNCTION SATISFACTORY.
ATE f !
Inspector
THE COMMONWEALTH OF MASSACHUSETTS
BOARD OF HEALTH
OF
B FEE
disposal
Permission is hereby granted
Construct ( ) or Repair (..j an Individual Sewage Disposal System
No:,. .
Street
on the application for Disposal Works Construction Permit No Dated
li 1.
arks Qtnuntrurttun Vrrmit
kTE
in 1255 Hoses a WARREN, INC.. PUBLISHERS
Bnerd of Health