471 Septic Application Permit & Plans 1994 CHECK OR FILL IN WHERE APPLICABLE
N
THE COMMONWEALTH OF MASSACHUSETTS
BOARD OF HEALTH
OF ( I
1 ppliratiun fur flinpunal Iii arks «Innstrnrtinn Prrm
Application is hereby made for a Permit to Construct ( ) or Repair (`) an Individual Sewage Disposal
System at:
Location-Address
or Lot No.
c s Ox1nir Address
Installer � Address
Type of Building Size Lot Sq. feet
Dwelling—No. of Bedrooms Expansion Attic (-5i) Garbage Grinder (r )
Other—Type of Building x No. of persons Showers ( ) — Cafeteria ( )
Other fixtures
Design Flow
Septic Tank—Liquid capacity
Disposal Trench—No.
Seepage Pit No Diamete
Other Distribution box ( ' ) Dosing tank ('" )
Percolation Test Results Performed by '
Test Pit No. 1 - minutes per inch
Test Pit No. 2 minutes per inch
gallons per person per day. Total daily flow - ' gallons.
gallons Length - Width Diameter Depth
Width Total Length Total leaching area . sq. ft.
Depth below inlet Total leaching area sq. ft.
Date
Depth of Test Pit Depth to ground water
Depth of Test Pit Depth to ground water
Description of Soil r '
Nature of Repairs or Alterations—Answer when applicable - -
Agreement:
The undersigned agrees to install the aforedescribed
the provisions of TITLE 5 of the State Environment
system in operation until a Certificate of Compliant
Application Approved By
Application Disapproved for the following rea
Individual Sewage Disposal System in accordance with
de—The un.- '_ned further agrees not to place the
aid of health.
gtaddkavt•Nf Leder 01. 13-‘34
G°').l -95/
Permit No.
Fe
Issued _ Date
Dor
THIS
by
at
has been installed in accordance with the provisions of TITLE 5 o The 4,4teenvironmental C
the application for Disposal Works Construction Permit No. 014— dated
THE ISSUANCE OF THIS CERTIFICATE SHALL NOT BE CONSTRUED AS A UA NTEE THAT THE
_
CER
THE COMMONWEALTH OF MASSACHUSETTS
BOARD OF HEALTH
tiL OF
Qlertifirati of Compliant
sal System constructed ( ) or Repaired (
the
ual Sewage
e es,dcesscribeelfy
SYSTEM WILL Fyg1CTION SAT ISF SCJDRy.
DATE . ��� '�
No* '%
Inspector
THE COMMONWEALTH OF MASSACHUSETTS
BOARD OF HEATH
A
OF
Bumps t Work Tapia, n permit
Permission is hereby gran ed
to Contra;�j�((�.'j ) pp(((��_RyQee 7�, ( an dividual a Disposal System
at No sti
as shown on the application for Disposal Works Construction Perm o. �t Dated "a jY fr F
-45 in
F
DATE
Form 1255 CHnW Hoses&WARRENM Publishers
of Health
OIA
tkIn fq
c- 47
912C
h 67E/0/ 3110 55 Li
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