307 Septic Application & Permit 1980 No
THE COMMONWEALTH OF MASSACHUSETTS
BOARD OF HEALTH
OF
F
Appiiratinu far liapn.5al 3ffnrlui C>Zauntrurtiau lgermit
Application is hereby made for a Permit to Construct ( ) or Repair ( ) an Individual Sewage Disposal
m
Syste at: t' �,J �"
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LaeStlon-Address
4-i�....) ("L'. I
OOwner j.Address
-1 t_-NA. "'r"f` r Installer- � Address
co iit U Type of Building
Size Lot Sq. feet
Dwelling—No. of Bedrooms Expansion Attic ( ) Garbage Grinder ( )
p. Other—Type of Building No. of persons Showers ( ) — Cafeteria ( )
d Other fixtures
• Design Flow gallons per person per day. Total daily flow ons.//
W
n4 Septic Tank—Liquid capacity; - gallons Length / n Width ri t Diameter Depth._. _
W
x Disposal Trench--No. Width Total Length Total leaching area sq. ft.
3 Seepage Pit No Diameter Depth below inlet Total leaching area sq. h.
z Other Distribution box ( ) Dosing tank ( )
Percolation Test Results Performed by Date
,'"lj Test Pit No. 1 minutes per inch Depth of Test Pit Depth to ground water
ra, Test Pit No. 2 minutes per inch Depth of Test Pit Depth to ground water
C4
O Description of Soil
0
w
UNature 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 iT LI 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 hoard of health.
Signed
Date
l
Application Approved By
Application Disapproved for the following reasons•
Dam
Date
Permit No Issued . ,
by
at
has been installed in accordance with the provisions of Ti`TLI 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 YIU.L FUNCTION SATISFACTORY.
DATE ` '< -_: - . ' s Inspector
THE COMMONWEALTH OF MASSACHUSETTS
BOARD OF HEALTH
-
Cnrrtifirtttr of (anniplittnrr
THIS IS TO CERTIFY, That the Individual Sewage Disposal System constructed ( ) or Repaired (�
(J
Installer
No
THE COMMONWEALTH OF MASSACHUSETTS
BOARD OF HEALTH
OF
33inpnnttl Marks @tnnntrurtinn jrrmit
Permission is hereby granted
to Construct ( ) or Repair ( ) an Individual Sewage Disposal System
at No
FEE
Street
as shown on the application for Disposal Works Construction Permit No Dated
Board of Health
DATE
FORM 1255 HOBBS & WARR EN. INC.. PUBLISHERS