24 Septic Application & Permit 1980 CHECK OR FILL IN WHERE APPLICABLE
No_..yt...�-3
THE COMMONWEALTH OF MASSACHUSETTS
BOARD OF HEALTH
OF % t"MThe ttli'en/
Application for Uispanal Works Cans trnrtinn lrrmit
FEB
S cc
Application is hereby made for a Permit to Construct
System at:
ay
pie ati&1-Address
mr.:mr
Type of Building
Dwelling— No. of Bedrooms
Other—Type of Building
Other fixtures
Design Flow gallons
Septic Tank—Liquid capacity gallons
Disposal Trench— No. Width
Seepage Pit No Diameter
or Repair
an India idual Sewage Disposal
or tot No.
Address
Address
Size Lot Sq. feet
Expansion Attic ( ) Garbage Grinder ( )
No. of persons Showers ( ) — Cafeteria ( )
Other Distribution box
Percolation Test Results
Test Pit No. I
Test Pit No. 2
Description of Soil
per person per day. Total daily flow gallons.
Length Width Diameter Depth
Total Length Total leaching area sq. ft.
Depth below inlet Total leaching area sq. ft.
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
Nature of Repairs or Alterations—An
when applicable ateli Y ' 30 e f
r
Agreement:
The undersigned agrees to install the aforedescribed Individual Sewage Disposal System in accordance with
the provisions oI TITLE 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 gy the ear of he
Application Approved By 't ef-t ik
Application Disapproved for the folio reasons.
Date
Permit No
Issued.
n
q Da[
_ly..._/-1..r(.
by
THE COMMONWEALTH OF MASSACHUSETTS
BOARD OF HEALTH
OF L)e_
rrtifiratr of Tomplianrr
THIS IS Tp CERTIFY, That the Individual Sewage Disposal System constructed ( ) or Repaired (k )
at : % tc4cr ! -
has been installed in accordance with the provisions of TIT ff. 5 of The State Sanitary code as described in the
application for Disposal Works Construction Permit No k dated y< t ft THE ISSUANCE OF THIS CERTIFICATE SHALL NOT BE CONSTRUED AS A GUARANTEE THAT THE
SYSTEM WILL FUNCTION (ISATISFACTORY.
DATE �; : t 7 Lib Inspector_..;_:rz
THE COMMONWEALTH OF MASSACHUSETTS
BOARD OF HEALTH
OF.
Disposal rQ inks tbonntrnrtion tirrmit
Permission is hereby granted
to Construct ( ) or Repair ( ) an Individual Sewage Disposal System
FEE . .
at No y._-..__n_ sdrect
as shown on the application for Disposal Works Construction Permit No Dated
Board of health-
DATE
FORM 1255 HOBBS & WARREN. INC., FUELISHERS