23 Application & Permit 1967 No.....
THE COMMONWEALTH OF MASSACHUSETTS
BOARD OF HEALTH
OF
Fax
Appliratinn far 3Jispnzal arks Qtnnstrnrtinn Vrrmit
Application is hereby made for a Permit to Construct ( ) or Repair (• ) an Individual Sewage Disposal
System at:
•
rr;
ion.Arid r a or Lot No.
Owner Address
Installer 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
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.
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
Other Distribution box
Percolation Test Results
Test Pit No. 1
Test Pit No. 2
Description of Soil
Nature of Repairs or Alterations—Answer when applicable
.1 ' / „• .k1 „s:2
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 been5issued by the boardrlof health,---
Signed
Application Approved By
Date
Date
Application Disapproved for the follouting reasons'
Date
Permit No Issued
Date '
by
THE COMMONWEALTH OF MASSACHUSETTS
BOARD OF HEALTH
OE .
trrtifirati of Olmtpliattre
THIS IS TO CERTIFX, Th4 the Individual Sewage Disposal System constructed ( ) or Repaired
Installer
at
has been installed in accordante with the provisions of Article CI of The State Sanitary Code as described in the
applicstEn for Disposal Works Construction Permit No cidfe," dated /44: 7
THE ISSUANCE OF THIS CERTIFICATE SHALL NOT BE CONSTRUED AS A GUARANTEE THAT THE
SYSTEM WILL FUNCTION SATISFACTORY.
DATE s_ L.11. t Inspector 41' s...
THE COMMONWEALTH OF MASSACHUSETTS
BOARD OF HEALTH
el.
or
No FEE
%Valid Ile litho Clintatraction hermit
Permission is hereby granted.
to Construct ( ) or Repair (V) an Individual Sewage Disposal System
at No
Street
as shown on the application for Disposal Works Construction Permit No - Dated
Board of Health
DATF
FORM 1255 HOBBS WARREN. INC., PUBLISHERS