11 Septic Application Permit & Compliance 1966 ECK OR FILL IN WHERE APPLICABLE
No i 1-
THE COMMONWEALTH OF MASSACHUSETTS
BOARD OF F-)EALTH
OF rf: ,+:3y
FEE
Application for Oinpnnttt or'who CInnntrurtinn Permit
Application is hereby made for a Permit to Construct (✓) or Repair ( ) an Individual Sewage Disposal
System at:
0 Install
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 eapa ity..lLtgallons Length Width Diameter Depth
Disposal Trench—No.sees :sees Width.A Q.'_..... Total Length_sa2 0 r Total leaching area L.f..t2..a..sq. ft.
Seepage Pit No Diameter Depth below inlet Total leaching area sq. ft.
Other Distribution box ( ) Dosing tank ( )
Percolation Test Results Performed by Date
Test Pit No. 1 minutes per inch Depth of Test Pit Depth to ground water
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
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 and rsigned further agrees not to place the system in
operation until a Certificate of Compliance has been issued by the b rd of k
Signed_o
Application Approved By i'e—rT
moo[/ /,4
Date
Application Disapproved for the following reasons-
Permit No / 1
Issued
Date
Data
by
at
THE COMMONWEALTH OF MASSACHUSETTS
BOARD OF HEALTH
dAjt OF
Trrtifiratt of (Compliancy.
THIS IS TVE IFY
hat the Mdividual Sewage Disposal System constructed ( ) or Repaired
-4-0,4-tr
Installer
)
has been installed in accordance with the provisions of Article )97f jhe State Sanitary C as silieeln n
application for Disposal Works Construction Permit No dated
THE ISSUANCE OF THIS CERTIFICATE SHALL NOT BE CONSTRUED AS A GUARANTEE THAT THE
SYSTEM WM FUNCTION SATISFACTORY.
DAT ' (1-0N-U .cA i V 46
Inspector 1, o- t-i l; Sit., i I im
No / 73
THE COMMONWEALTH OF MASSACHUSETTS
BOARD OF HEALTH
6t-4,e, OF SOL--Ciceit
UinpittialPortai Tattotrurtion
Permissiontifrfiereby granted £244€
to Construct (y) t Repair C ) an Individual Savage Disposal System
at No ./
FEE
street
as shown on the application for Disposal Works Construction Permit No.1.73 Dated
Hoar& oi Heat
DATE 4419.....]:2.1 ".0
FORM /255 HOCBS & WARREN. INC.. PUBLISHERS