214 Septic Permit IN WHERE APPLICABI
CHECK OR Fl
as
Type of Building
Dwelling—No. of Bedrooms �t
Other—Type of Building No.
Other fixtures
Design Flow .-: gallons per person per day. Total daily flow
Size Lot Sq. feet
Expansion Attic ( ) Garbage Grinder (y
of persons Showers ( ) — Cafeteria ( )
Septic Tank—Liquid ca
Disposal Trench--No. Width Total Length
Seepage Pit No Diameter Depth below inlet
Other Distribution box ( ) Dosing tank ( )
Percolation Test Results Performed by
Test Pit No. 1 minutes per inch Depth of 'pest Pit
Test Pit No. 2 minutes per inch Depth of Test Pit
gallons.
pacity gallons Length Width Diameter Depth
Total leaching area sq. ft.
Total leaching area sq. it.
Date
Depth to ground water
Depth to ground water
Description of Soil
Nature of Repairts or Alterations—Answer when pplicab e
II lull-
Agreement:
The undersigned agrees to install the aforedescribed Individual Sewage Dssposal System in accordance with
the provisions of_IT . 5 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 health.
Pt,—I' ,l/ r
Application Approved By
Oc[
t F
i-
Date
Application Disapproved for the following re&ons•
by
at
has been installed in accordance with the provisions of TIT The State Sanitary C
application for Disposal Works Construction Permit No n dated _>
THE ISSUANCE OF THIS CERTIFICATE SHALL NOT BE CONSTRUED AS A G
SYSTEM WILL F /µ/C ION SATISFACTORY.
DATE r'.G f F Inspector
Permit No
Issued_
THE COMMONWEALTH OF MASSACHUSETTS
BOARD OF HE LTH
OF
@Trrtifiratr of ant* nu
Sewage Disposal System constructed ( ) or Repaired (!�
Date
THIS IS TO(AER FY
2-
THE COMMONWEALTH OF MASSACHUSETTS
BOARD OF HEALTH
i
OF 01- ^7r
FEE
Buyout Works Qtonntrtutioq 1. nmii.
Permission is hereby granted
No
to Construct ( ) or Repair ( /-jpn Individual Sewage Di
at No
a!
sneer
as shown on the application for Disposal Works Construction Permit No. C l Dated > J r y
BaardA Health
System 1
DATE //
f�C
FORM 1255 HOBBS & WARREN, INC.. PUBLISHERS
CHECK OR FILL IN WHERE APPLICABLE
THE COMMONWEALTH OF MASSACHUSETTS
Fzio It"..._ , .`.
Apptiratiun fur £tispustti lurks Cnunstrurtiun 'lJermit
Application is hereby made for a Permit to Construct (
System at:
id.
-2H fX vim '" r4
) or Repair ( Individual Sewage Disposal
Type of Building
Dwelling— No. of Bedrooms
Other Type of Building
Other fixtures
Design Flow 5— gallons
Septic Tank--Liquid capacity gallons
Width______ _____________ Total Length
Diameter Depth below inlet
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
Address
Size Lot Sq. feet
Expansion Attic ( ) Garbage Grinder (t4-
No. of persons Showers ( ) — Cafeteria ( )
per person per day. Total daily flow 66”9-gallons/
Length Width Diameter Depth
Total leaching area sq. ft.
Total leaching area sq. ft.
Disposal Trench—No.
Seepage Pit No
Other Distribution box (
Percolation Test Results
Test Pit No. 1
Test Pit No. 2
Description of Soil
Nature of Reps:(tj,s�os.r Alterations— nswer when applic..1e.
a– /u x t 1. /tA-"r•-ei
Agreem t:
The undersigned agrees to install the aforedescribed Individual Sewage Disposal System in accordance with
the provisions of T_..... 5 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 hoard of health.
Application Approved By
ed-
Application Disapproved for the following r(0 r
Permit No
Issued.
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