579 Septic Application Permit & Compliance CHECK OR FILL IN WHERE APPLICABLE
THE COMMONWEALTH OF MASSACHUSETTS
BOARD OF HEALTH
OF
Application for Disposal
Hr;
FEE
orks (lIonstrurtion permit
Application is hereby made for a Permit to Construct ( ) or Repair (75 an Individual Sewage Disposal
System at:
Location,Address or Lot No.
Ow er
Address
Installer 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 futures
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 sq. ft.
Seepage Pit No Diameter 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
Other Distribution box
Percolation Test Results
Test Pit No. 1
Test Pit No. 2
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 %I 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 board of health.
Signed._
Date
Application Approved By
Date
Application Disapproved for the following reasons
Permit No - 1 Issued
Date
THE COMMONWEALTH OF MASSACHUSETTS
BOARD OF HEALTH
Ohl-filtrate of Citampliattrr
THIS IS TO CERTIFY, That the Individual Sewage Disposal System constructed ( ) or Repaired (/5
by
Installer
at
has been installed in accordance with the provisions of Article XI of The State Sanitary 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 —
No FEE
itisponal arkn entotrurtinn ihrtnit
Permission is hereby granted
to Construct ( ) or pair it ( i an Individual Sewage Disposal System
at N
Street
as shown on the application for Disposal Works Construction Permit No ....------------ Dated
DATE
FORM 1255 HOBBS a WARREN. INC.. PUBLISHERS
Board of Health