435 Septic Application & Permit No
THE COMMONWEALTH OF MASSACHUSETTS
BOARD OF HEALTH
OF
FEE
1pplirntian for iflispasul Works Cnanstrurtian Prrmit
Application is hereby made for a Permit to Construct ( ) or Repair (V) an Individual Sewage Disposal
System at:
Location-Address
Owner
aInstaller
d Type of Building
V Expansion Attic (
Dwelling— No. of Bedrooms No
p. Other—Type of Building
6
W Design Flow
e4 Septic Tank—Liquid capaci4-
zDisposal Trench No
Seepage Pit No
z Other Distribution box
Percolation Test Results
'.7 Test Pit No. 1
u, Test Pit No. 2
or Lot No.
Address
Address
Size Lot Sq. feet
Garbage Grinder ( )
of persons Showers ( ) — Cafeteria ( )
gallons.
Other fixtures
gallons per person per day. Total daily flow Depth
Width Total Length leaching gallons Length Width Diameter _ P
Total leachin area�i '
Diameter Depth below inlet Total leaching area
) Dosing tank ( ) Date
Performed by
minutes per inch Depth of Test Pit Depth to ground water
minutes per inch Depth of Test Pit Depth to ground water
a
0 Description of Soil
V
U
sq. ft.
sq. ft.
o � .a1. ,.
Nature of Re p errs r Alterations Answer when applicable...
, L �+ -lt .,. A if
Agreement:
The undersigned agrees to install the aforedescribed Individual Sewage Disposal-System in accordance with
the provisions of:rI° 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
Signed
Application Approved By
Application Disapproved for the folio.:ng reasons'
Date
Date
Permit No
Issued
Date
Dam
by
at — of The State Sanitary Cede as described in the
has been instilled in accordance with the provisions of TITLE dated
application for Disposal Works Construction Permit No
THE ISSUANCE OF THIS CERTIFICATE SHALL NOT BE CONSTRUED AS A GUARANTEE THAT THE
SYSTEM WILL FUNCTION SATISFACTORY.
THE COMMONWEALTH OF MASSACHUSETTS
BOARD OF HEALTH
OF _. . . __. .
(4rrtifirttte of Qlnmplittnre
THIS IS TO CERTIFY, That the Individual Sewage Disposal System constructed ( ) or Repaired ( )
m.<aIIer
DATF
No
Inspector
THE COMMONWEALTH OF MASSACHUSETTS
BOARD OF HEALTH
OF . ... .. .. . .... . . . . . . .
Disposal Works ((Construction Permit
Permission is hereby granted,
to Construct ( ) or Repair ( ) an Individual Sewage Disposal System
at No Street a
as shown on the application for Disposal Works Construction Permit No
Dated
DATE
FORM 1253 HOBBS & WARREN. INC.. PUBLISHERS
Board of Health