477 Septic Application & Permit 1971 THE COMMONWEALTH OF MASSACHUSETTS
BOARD OF HEALTH
OF _.._ ... . .
Application for Blowing i,r;nrkO (IInstr
Application is hereby made for a Permit to Construct ( ) or Repair ) an Individual Sewage Disposal
System at: ,. .�
Fee -
on Permit
...................___r..., 0 L...... Address
........ usta_..—........._..._...................... Address $q. feet
Type oBuild n 1i t n Size Lot
- -.. V ns� e. � Garbage Grinder ( )
Type of Building Expansion Attic ( ) — Cafeteria ( )
Otheri—Type of Bedrooms No of persons Showers ( )
OthK—Tyhe of Building gallons
.
Other fixtures
---,,.--,..gallons per person per day. Total daily O4Diameter Depth......---..._.
Design Flow._._....___.._....._. Width
gallons Length Total leaching area sq. ft.
Septic Tank nc Liquid capacity ga Total Length
Disposal Pit No No..._._.Di meter h Total leaching area sq. ft.
Seepage Pit No..._._._.._._.. Diameter.._._._..._._. Depth below inlet
Dosing tank ( ) Date
Other Distribution Test box u ( )
Percolation Test Results Performed by Depth th to ground water_.._._._.._.._._
Depth to ground water
Nature Pit No. 1._._._-._.emotes per inch Depth of Test Pit
Test Pit No. 2........_.._-.nrrnutes per inch Depth of Test Pit eP
or Lot No.
Address
Description of Soil
Nature of Repairs or Alterations—Answer when,applinhle r�•
yam... '✓ ,.
................_..
.._.._.._.._..............
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 eued by the board of further agrees not to place the system in
operation until a Certificate of Compliance h sa✓hWt
..:.......... .
SigneZl'.::...::.....
t _Date
.._....-y.;Date
Application Approved By -/I -
Application Disapproved for the following reasons:...__.._._....._........._ __.._._..._.._._.__..._.._Q.._.._..._..._._.
Date
Permit No 1
Issued
by
r .
at + i.. .
has been installed in accordance with the provisions of Article XI of The State Sanitary
dated Code as described in the
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.
( Inspector , ({
DATE "� • ^` "I
THE COMMONWEALTH OF MASSACHUSETTS
BOARD OF HEALTH
THE COMMONWEALTH OF MASSACHUSETTS
BOARD OF HEALTH
OF
Otrrtificatt of nn pliu t n
THIS IS,-TO CERTIFY, That the Individual Sewage Disposal System constructed ( ) or Repaired (/7
Installer
No
OF
iiispnsal
rii
nrks. (linnstrurtinn Permit
Permission is hereby granted I dividbal-SCW;<Ke Disposal System
to Construct ( ) or Repair, ( ' Z q
at No Street
as shown on the application for Disposal Works Construction Permit No i Dated
i Boca
of Hellth
DATE
FORM 1255 HOBBS & WARREN. INC.. PUBLISHERS