255 Septic Permit 1974 ERE APPLICABLE
CHECK OR FILL IN
No.fit
THE COMMONWEALTH OF MASSACHUSETTS
BOARD OF HEALTH
OF
Pax./... ; 6
Application for iflitipooat lfiorks uuutrurtiou if rrmit
ton is hereby made for a Permit to Construct ( or Repair ( ) an Individual Sew
Application age Disposal
System at: aa(( ///., �7— ��7�
O.S65 f..` atez-ma1�yliAt-t
.op
l..f.e...v
butaa r
Type of Building
Dwelling—No. of Bedrooms
Other—Type of Building
Other fixtures
or Lot so.
Address
Address
Size Lot Sq. feet
Expansion Attic ( ) Garbage Grinder ( )
No. of person+ Showers ( ) — Cafeteria ( )
Design Flow jj�� gallons per person per day. Total daily
Septic Tank—Liquid capacitJa3 4allons Length Widdt
Disposal Trench—No. Width Total Length
Seepage Pit No (Diameter Depth below inlet
Dosing tank ( )
Performed by
minutes per inch Depth of Tcst Pit
minutes per inch Depth of Test Pit
s' gallons.
Diameter Dgnh
Total leaching area ._�QV_U_sq. ft.
Total leaching area sq. it-
Other Distribution box (
Percolation Test Results
Tea Pit No. 1
Test Pit No. 2
Date
Depth to ground eater
Depth to ground water
Description of Soil
Nature of Repairs or Alterations—Answer when applicable
Agreement:
The undersigned agrees to install the aforedescrihed Individual Sewage Disposal System in accordance with
the provisions of Article NI of the State Sanitary Code—The nndcrsigued further agrees not to place the system in
operation until a Certificate of Compliance has beytt issued b the oa d of he lth.el:
Application Approved By
Application Disapproved for the following reasons'
Permit No
Issued ._sic i 4.7.y.
by
THE COMMONWEALTH OF MASSACHUSETTS
BOARD OF HEALTH
OF
Qlrrtifiratr of Tompliaurr
THIS IS TO CERTIFY, That the Individual Sewage Disposal System constructed ( ) or Repaired (
at
has bccn installed in accordance with the provisions of :Article N1 of The State Sanitary Code as described in the
application for Disposal Works Construction Permit No dated
THE ISSUANCE OF THIS CERT!FtCATE SHALL NOT BE CONSTRUED AS A GUARANTEE THAT THE
SYSTEM WILL FUNCTION SATISFACTORY.
DATE
Inspector