86 Sepic Application & Permit 1971 7
No.. -<-../..
THE COMMONWEALTH OF MASSACHUSETTS
BOARD OF HEALTH
. � ci y. /11/,`Y/
Application f Thnpnnnl
'li oxlip &nnstnirtinn 33Pxinif
Application is hereby made for a Permit to Construct ( ) or Repair an an Individual Sewage Disposal
System at: ,,..
T
installer-- /
G Type of Building
H Dwelling—No. of Bedrooms
a Other—Type of Building
Other fixtures - -- --_gallons per person per day. Total daily flow
Design Flow_.._.._..............._.... g Diameter
gallons Length....._---_.-.-Width Total leach
Z Septic Tank Trench capantY Total Length
Disposal Trench—No..................... Width
Diameter................. Depth below role
or Lot No.
Address
Address
Size Lot Sq. feet
Expansion Attic ( ) Garbage Grinder ( )
Showers ( ) — Cafeteria ( )
No. of persons
gallons.
Depth
leaching area sq.ft.
Total leaching area sq. it
Seepage Pit No Dosing
z Other Distribution box ( )
"" Percolation Test Results Performed by
aTest Pit No. 1.__._.._..minutes per inch
G4 Test Pit No. 2....... ... .
minutes per inch
tank ( ) Date.
Depth of Test Pit Depth to ground water
Depth of Test Pit Depth to ground water
�U Description of Soil
eC `
Nature of Repairs or Alterations—Answer when applitable_ !j U
The undersigned agrees to install the aforedescribed Individual Sewage Disposal System in accordance with rt
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/ssued by the board of health.
Signed—,.,1.`� f.X -t ta...... rti
Application Approved By .!!
Application Disapproved for the following reasons
Permit No_:f
'i„
Di".
Datd
Issued
rt
Date
THE COMMONWEALTH OF MASSACHUSETTS
BOARD OF HEALTH
......... . . OF
Ott-Ott& of Taittplfattat
THIS IS TO CERTIFY, That the Individual Sewage Disposal System constructed ( ) or Repaired ( )
by.. . Installer
at .. ....
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.................................. date&... .................. .... .............
THE ISSUANCE OF THIS CERTIFICATE SHALL NOT BE CONSTRUED AS A GUARANTEE THAT THE
SYSTEM WILL FUNCTION SATISFACTORY.
DATE................................................................................ Inspector........................ .........................................................
THE COMMONWEALTH OF MASSACHUSETTS
BOARD OF HEALTH
No "1,3 1 . .. ..C.1, C.4 OF jitt !. k4. ,, ta;:.CII.;......................
0 li
ilisposat arks Tonstrurtinat Iltrittit
Permission is hereby grantecl........1/4.444.:......-Ls....—:.... 4..‘„,...(...., ............................................................
to Construct (,.. ) or Repair 17) an/Individual Sewage DisPo(sal Systern
at No
. ................................ .......................................................................
Street
as shown on the application for Disposal Works Construction PermitN0..4...i.
I -I
f- k
A 137;;;4d of;‘elartfh.. '‘
DATE................................................................................
FORM 1255 HOBE s & WARREN. INC- PUBLISHERS