981 Septic Appication 1968 CHECK OR FILL IN WHERE APPLICABLE
No FEE
THE COMMONWEALTH OF MASSACHUSETTS
BOARD OF HEALTH
OF....:
Applirntinn for flis#Insal cc nrkn Qlnnntrnrtinn 1rrmit
Application is hereby made for a Permit to Construct ( ) or Repair (' ) an Individual Sewage Disposal
System at: - - -
i i / �a-
..........._.._ Locanoe- or Lot No.
, 1. !,'y,!.n
_......._.__..__1.a o „1,.�. "R.iT r �
f D Address
.1 N- (ttti
J Installer Addss
Type of Building Size Address Lot
Sq. feet
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
Di gallons.
Septic Tank—Liquid capacity gallons Length Width ameter Depth
Disposal Trench—No. Width Total Length Total leaching area sq. ft.
Seepage Pit No Diameter Depth below inlet Total leaching area sq. ft.
Other Distribution box ( ) Dosing tank ( )
Percolation Test Results Performed by Data
Test Pit No. I 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
Nature of Repairs or Alterations—Answer when applicable.....as
Agreement:
The undersigned agrees to install the aforedescribed Individual Sewage Disposal System in accordance with
the provisions of Article XI of the State Sanitary Co e— The undersig ed further agrees not to place the system in
operation until a Certificate of Compliance has been i sued by the board
J r .r ( -h r, r,,
Signed .. - . .
/Dater
f i .ILL ter• .: ` -�.
k
Application Approved B
Application Disapproved for the following reasons
Date
Permit No.
Date
Issued..:
Date
THE COMMONWEALTH OF MASSACHUSETTS
BOARD OF HEALTH
d rtifirttte of flinm}xlittnre �
THIS IS TO CERTIFY, That the Individual Sewage Disposal System constructed ( ) or Repaired l"
by - ly maauee
at y '-1 �_:< i .. LL 's"
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 !UNCTION SATISFACTORY.
DATE ,„ " I - J ' Inspector
No.
THE COMMONWEALTH OF MASSACHUSETTS
BOARD OF HEALTH
OF l�. I Tr,
.
FEE
Disposal ark nnstrnrtinn jermit
Permission is hereby grantedf is az eL Lrf
to Construct ( ) or Repair (Y ) an Individual,Sewage Disposal System
at No
Street
as shown on the application for Disposal Works Construction Permit No Dated ' ' s
Board of 4elth
DATE
FORM 1255 HOBBS & WARREN. INC.. PUBLISHERS