15 Septic Application & Permit 1968 y7 7 5
ft /5 1, h
Na is 5
h
No
THE COMMONWEALTH OF MASSACHUSETTS
BOARD OF HEALTH
FEB
OF . 'rrr
Appliratiuo for Dii pomit Gc nrks @innstrurtion 'Permit
Application is hereby made for a Permit to Construct ( ) or Repair ( ) an Individual Sewage Disposal
System at:
ton Address
or Lot No.
Address
ow-er
1..1 3ti
r Installer Address Sq. feet
Type of Building Size Lot q
Garbage Grinder ( )
Other—Type
Dwelling Type No.—
of Building p of Bedrooms Expansion Attic ( )
of persons Showers ( ) — Cafeteria ( )
Other fixtures gallons
Design Flow gallons per person per day. Total daily flow
Septic Tank—Liquid capacity gallons Length Width Diameter Depth
Disposal Trench—No. Width Total Length TTtalal leaching area
reaa sq. ft.
Seepage Pit No Diameter Depth below inlet g
Other Distribution box ( ) Dosing tank ( )
Date
Percolation Test Results Performed by De th to ground water
Test Pit No. 1 minutes per inch Depth of Test Pit P g
Test Pit No. 2 minutes per inch Depth of Test Pit Depth to ground water
Description of Soil
Nature of Repairs or Alterations—Answer when applicable
„r
Agreement:
The undersigned agrees to install the aforedescribed Individual Sewage Disposal System in accordance with
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 beery issued by the board of health.
1 .a '
Signed. /- • fr Date
.. _ . . t
d�
Application Approved By • f1 •+ Date
Application Disapproved for the following reasons'
Permit No
Issued.
Date
Date
by
has been installed in accordance with the provisions of Article XI of The State Sanitary
dated
Code as described in the
application for Disposal Works Construction Permit No
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
OF .. . . . . . .... . . . _ .. .
fertifiratr of Qinmpliattre
THIS IS TO CERTIFY, That the Individual Sewage Disposal System constructed ( ) or Repaired ( )
Installer
No
THE COMMONWEALTH OF MASSACHUSETTS
BOARD OF HEALTH
OF A'- .?.
Einpnnal
nrk2HQtnnutrttr'tina j rrmit
Fae
Permission is hereby granted,..
to Construct ( ) or. Repair (Y) an Individual Sewage Disposal System
at No 't -� r
Street
as shown on the application for Disposal Works Construction Permit No - '
Dated
DATE
FORM 1255 HOBBS & WARREN. INC.. PUBLISHERS
Board of Health