160 Septic Application & Permits CHECK OR PILL IN WHERE APPLICABLE
THE COMMONWEALTH OF MASSACHUSETTS
BOARD OF HEALTH
Fax
Application fur 13)i51►nnal MMurkt( Qtnnsirnrtinn firrmit
Application is hereby made for a Permit to Construct ( ) or Repair Klan Individual Sewage Disposal
System at:
LocaLLetl-Address or Lot No.
- ?
Ow
Type of Building
Dwelling—No. of Bedrooms
Other—Type of Building
Other fixtures
Design Flow
Septic Tank—Liquid capacity
Disposal Trench—No.
Seepage Pit No
Other Distribution box
Percolation Test Results
Test Pit No. 1
Test Pit No. 2
' CC
jnstaller Address
Size Lot Sq. feet
Expansion Attic ( ) Garbage Grinder ( )
No of persons Showers ( ) — Cafeteria ( )
Address
gallons per person per day. Total daily flow gallons.
gallons Length Width Diameter Depth
Width Total Length Total leaching area sq. ft.
Diameter Depth below inlet Total leaching area sq. ft.
Dosing tank ( )
Performed by
minutes per inch
minutes per inch
Date
Depth of Test Pit Depth to ground water
Depth of Test Pit Depth to ground water
Description of Soil
Nature of Repa
or Alterations—Answer when applicable
<stra.:w 5.D.A
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—The undersigned further agrees not to place the system in
operation until a Certificate of Compliance has been issued by the b2Xr of_
Signed r l 7
- .1::..Ce...(::: 0.. •—
Application Approved By a::L.0 ' • ,4 .'Z....,.' Cfcrt:;'LCC'i
C
Application Disapproved for the following reasons
7:1 l
Date
Permit No Issued._
Date
l
by
THE COMMONWEALTH OF MASSACH USETTS
BOARD OF HEALTH
OF
(Qertifiratr of slmnitlitittrr
THIS IS TO CERTIFY, That the Individual Sewage Disposal System constructed ( ) or Repaired (
Installer
has been installed in accordance with the provisions of Article XI of The State Sanitary Code as described in the
applimtirm for Disposal Works Construction Permit No - — dated
THE ISSUANCE OF THIS CERTIFICATE SHALL NOT BE CONSTRUED AS A GUARANTEE THAT THE
SYSTEM WILL FUNCTION SATISFACTORY.
DATE —...._._.__ Inspector
No.. -- x
THE COMMONWEALTH OF MASSACHUSETTS
BOARD OF HEALTH
OF C-.`_,9.Lt ,ti..: t(c
f f
flispnsal li nrks (IInnstrnrtian Permit
Permission is hereby grant ./ j¢ S .x L
to Construct ( ) or Repair ( . ) an Individual Sewage isposal System
at No f_i ! AAL.:.
Street
as shown on the application for Disposal Works Construction Permit No._4 -
DATE
FORM 1255 ROBES & WARREN. INC.. PUBLISHERS
FEE
Dated =%r.v I,._%. f... .
Board of Health.
"HERE APPLICABLE
CHECK OR FILL IN
�v
Fax
• ' THE COMMONWEALTH OF MASSACHUSETTS
BOARD OF HEALTH
r
Application fur Disposal arks &instrurtiun 'Prnttt
Application is hereby made for a Permit to Construct
System at:
y ..
Location•Addre
Owper
Lntaller
Type of Building
or Repair ( ) an Individual Sewage Disposal
or Lot No.
Address
Dwelling No. of Bedrooms Expansion Attic
Other—Type of Building No. of persons
Other fixtures
Design Flow gallons per person per day. Total daily flow gallons.
Septic Tank—Liquid capacity..jj(, Lgallons Length Width Diameter Depth
Disposal Trench—No. Width Total Length Total leaching area...a,�s..0 sq. ft.
Seepage Pit No Diameter Depth below inlet Total leaching area sq. ft.
Other Distribution box ( ) Dosing tank ( )
Percolation Test Results Performed by Date
Test Pit No. 1 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
Address
Size Lot Sq. feet
Garbage Grinder ("4
Showers ( ) — Cafeteria ( )
Description of Soil
Nature of Repairs or Alterations—Answer when applicable
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—The undersigned further agrees not to place the system in
operation until a Certificate of Compliance has been issued by the board of health.
Application Approved By
reasons
Signed
Date
i
Date
Date
Application Disapproved for the following
Permit No - Issued - z
•
THE COMMONWEALTH OF MASSACHUSETTS
BOARD OF HEALTH
OF
trrtifiratr of CCnmplianrr
THIS IS TO CERTIFY, That the Individual Sewage Disposal System constructed (/) or Repaired ( )
by 4
at .. .. ..._... '.,! _ mn.0 _. . .... ..:w.
has been installed in accordance with the provisions of Article XI of The Stare Sanitary Code as described in the
application for Disposal Works Construction Permit No dated -. r - !
THE ISSUANCE OF THIS CERTIFICATE SHALL NOT BE CONSTRUED AS A GUARANTEE THAT THE
SYSTEM WILL FUNCTION SATISFACTORY.
DATE Inspector
No
THE COMMONWEALTH OF MASSACHUSETTS
BOARD OF HEALTH
OF -
Disposal rIl arks Minutia/inn rrmii
FRE
Permission is,areby granted .,.
to Construct ( .4 or Repair ( ) an Individual Sewage.Disposal 5y stem
at No - - _.._.
Street
as shown on the application for Disposal Works Construction Permit No..__..:.........-.. Dated -- '
Board of Health
DATE
FORM 1255 HOBBS & WARREN. INC.. PUBLISHERS
IN WHERE APPLICABLE
CHECK OR
No• FEE
THE COMMONWEALTH OF MASSACHUSETTS
Application
BOARD OF .EALTH
or Disposal Works (t" structiuu lrrucit
Application is hereby made for a Permit to Construct (,X) or Repair ( ) an Individual Sewage Disposal
Sysggm y(:
non-Addy
... .._14 _ sue. .. �_Kdlfa/.:et—/__
Owner
Address
Installer v Address 3 /xt/t
Type of Building Size Lot.J .. f<`—Sq.
... ..._.. feet
Dwelling—No. of Bedrooms 3 Expansion Attic ( ) Ga ge Grinder ( )
Other—Type of Building .. No. of persons Showers ( ) — Cafeteria ( )
Other fixtures �i..L..A/J(�`
Design Flow '1 V gallons er person per d%. Total daily flow /07...0:0 gallons.
Septic Tank-Liquid capacity gallons Length Width Diameter Depth
Disposal Trench—No. Width ������'''''' Total Length Total leaching area sq. ft.
Seepage Pit No Diameter .th belo i et _ Total leaching area sq. ft.
Other Distribution box ( ) Dosin. l ) 9
Percolation Test Results Performed by / .. .. .._ �7n VA Date. ^LZ7
Test Pit No. 1...J.D minutes per inch Iepth of Test Pit..Cia epth to groun water9
Test Pit No. 2 minutes per inch Depth of Test Pit Depth to ground water �n I .
' ) /J ._ A-.t�i4-
Description of Soil {,y...2�,{....=4=C_8-��-�{ .. � .�i4�-�..... •
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 XI 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.
Application Approved By
Signed
Application Disapproved for the following reasons•
Date
Date
Date
Permit No Issued
Daze