435 Septic Application & Permit 1974 .
5
No._(q..y.J.._..
1XE:
CHECK OR FILL IN WHERE APPLICABLE
THE COMMONWEALTH OF MASSACHUSETTS
BOARD OF HEALTH
OF
Aoptiratinn fur flia}Tnsttl 3finrkn `C2nn itrur zt rrntit
made for a Permit to Construct
or Repair ( an
Application is hereby
System at:
n n r .tin - Ad c
L . .._ ((jj am�
insstallet
lndiridual Sewage Disposal
or Lot No.
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 capacity gallons Length Width Diameter Depth_
Disposal Trench—No. Width Total Length Total leaching area
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
/�T/ p
Nature of Repairs or Alterations—Answer when applicable Irk/�sjp-- - � Paid'
Agreement:
The undersigned agrees to install the aforedescribed Individual Sewage Disposal System in accordance with
the provisions of Article NI of the State Sanitary Code—The undersigned further agrees not to place the system in
operation until a Certificate of Compliance has ggn issued b the ..ard of health.
Signe(K7 ' I I it L
{ %c ./97/
Application Approved By += ° Date
Application Disapproved for the folio
g reasons•
// na�c
Permit No._!Q >1 Issued 4 n�3 �7y
e
THE COMMONWEALTH OF MASSACHUSETTS
BOARD OF HEALTH
OF
Ctlrrtifiratt of (dnm}Tliaurr
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 Ni 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 WILL FUNCTION SATISFACTORY.
DATE inspector
THE COMMONWEALTH OF MASSACHUSETTS
BOARD OF HEALTH
OF
Cnertifirate of fanmplianre
THIS IS TO CERTIFY, That the Individual Sewage Disposal System constructed ( ) or Repaired
)
by m.t.aller
at
has been installed in accordance with the provisions of Article XI of The State Sanitary t 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
No �� '
THE COMMONWEALTH OF MASSACHUSETTS
BOARD OF HEALTH
i r. . L.. OF ")7...rAl,Irf^r;f`or,
Dinpnnal t %Marko Cnnpstrur$Inn �rrmit
., s
Permission is hereby granted..f
to Construct ( ) or Re*ir ( an Individual Sewage Disposal Sys
at No
as shown on the application for Disposal Street
p Works Construction Pen No tll. f` DatedA-- -/./1(
'/. . ed
Board of Health
FEE 5 A A
DATE
FORM 1235 HOBBS h WARREN. INC_ PUBLISHERS