31 Septic Application & Permit 1975 CHECK OR FILL IN WHERE APPLICABLE
No
Fits—
THE COMMONWEALTH OF MASSACHUSETTS
BOARD OF HEALTH
OF
Application for Qinponal than Clonstrurtiott Permit
Application is hereby made for a Permit to Construct ( ) or Repair (✓") an Individual Sewage Disposal
System at:
Location-Address
Owner
or Lot No.
Address
Installer Address
Type of Building Size 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 gallons.
Septic Tank--Liquid capacity M.—.. gallons Length Width Diameter 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
Percolation Test Results
Test Pit No. I
Test Pit No. 2
Dosing tank ( )
Performed by Date
minutes per inch Depth of Test Pit Depth to ground water
minutes per inch Depth of Test Pit Depth to ground water
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:Hi: 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
Dal
Date
Oat
ff
Application Approved By
Application Disapproved for the following reasons
Permit No Issued_
Date
by
THE COMMONWEALTH OF MASSACHUSETTS
BOARD OF HEALTH
OF
(Ertl- irate of (llnntplianrr
THIS IS TO CERTIFY, That the Individual Sewage Disposal System constructed ( ) or Repaired ( )
Installer
at
has been installed in accordance with the provisions of TITLE 5 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 FUNCTION SATISFACTORY.
DATF Inspector
THE COMMONWEALTH OF MASSACHUSETTS
BOARD OF HEALTH
OF
No - FEE
Bispoonl
Permission is hereby granted !!- I
to Construct ( ) coy Repair ('gran Individual Sewage Disposal Sjirem
at No
sweet
as shown on the application for Disposal Works Construction Permit No Dated C
arks i>Innstrurtinn Permit
Board of Health
DATE
FORM 1255 HOBBS S WARREN. INC.. PUBLISHERS