123 Septic Permit ECK OR FILL IN WHE
Type of Building
Dwelling—No. of Bedrooms Expan
Other—Type of Building No of persons
Other fixtures
Size Lot Sq. feet
on Attic ( ) Garbage Grinder ( )
Showers ( ) — Cafeteria ( )
Design Flow
gallons per person per day. Total daily flow gallons.
Septic Tank—Liquid capacity gallons
Disposal Trench—No Width
Seepage Pit No Diameter
Other Distribution box ( ) Dosing tank ( )
Percolation Test Results Performed by
Test Pit No. 1 minutes per inch
Test Pit No. 2 minutes per inch
Length Width Diameter Depth
Total Length Total leaching area sq. ft.
Depth below inlet Total leaching area sq. ft.
Date
Depth of Test Pit Depth to ground water
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 been issued by the board of heakh.
Signed
Date
Date
1te
Application Approved By
Application Disapproved for the following reasons•
by
Permit No
Issued {Date—
THE COMMONWEALTH OF MASSACHUSETTS
BOARD OF HEALTH
OF
fllrrtifirate of Tomplinnre
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
No
THE COMMONWEALTH OF MASSACHUSETTS
BOARD OF HEALTH
OF
Disposal
hi;
irks ftnnstrurtinn l rrmit
FEE
Permission is hereby granted_.
to Construct ( ) or Repair ( t') an Irfdividual.Sewage Disposal System
at No
Street
as shown on the application for Disposal Works Construction Permit No - Dated
DATE
FORM 1255 HOBBS & WARREN. INC.. PUBLISHERS
Board of Health
VHERE APPLIC.
CHECK OR FILL
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 s:5-(9 sq.ft.
Seepage Pit No Diameter Depth below inlet Total leaching area sq. ft.
Other Distribution box ( ) Dosing tank ( )
Percolation Test Results Performed by Date
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
Description of Soil
7
Nature of Repairs or Alterations—Answer when applicable /�•� �+`x-E A�i
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 been issued by the board of h�a4I1.�__
Signed �. . Ll..a•� :4-4' �i e, k.i..t t __
,.,4114 riV4
Application Approved By -
'I
! :, /7 /
Issued ?t
! ] 7 s
Cttir 92 22
mete
Application Disapproved for the following reasons'
by
a
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
Permit N
Date
L out
THE COMMONWEALTH of MASSACHUSETTS
BOARD OF HEALTH
QLrrtifirntr of (tnmplixnrr
THIS !ST() (ERTIF�' Th t the Individual Sewage Disposal System constructed ( ) or Repaired (P
d, J
R4 -1640.'
Installer
dated .e'.Ll._lei a--
THE ISSUANCE OF THIS CERTIFICATE SHALL NOT BE CONSTRUED AS A GUARANTEE THAT THE
SYSTEM WILL FUNCTION SATISFACTORY. __ r
DATE CAA / 412 /`f4 a f Inspector . -aYIA— 4. / 6rrfftEEtJ
THE COMMONWEALTH OF MASSACHUSETTS
BOARD/, OF HEALTH fi op
No 1 (1 FEE
igispoo llPnrlo atD1t.6trurtinit rYmit
Permission is hereby grante r-""h. -
onstruct ( ) or Repair ) aq- dividual Sewage Disposal Sy
to C System
at No f �i 3 L4 to (,,.�A..1' 'slid
street
as shown on the application for Disposal Works Construction Permit No Dated "12
DATE 11 ' WF -
FORM 1255 Hone & WARREN. INC.. PUBLISHERS
Board of H{jltb