601 Septic Application Permit & Compliance CHECK OR FILL IN WHERE APPLICABLE
No � V
-2
1
THE COMMONWEALTH OF MASSACHUSETTS
„BOARD O F HEALTH
OF 21Qi-i.:foL/lt
Applirntian far 33inpanal
511
nrkn (fIanntrnrtinn Permit
Application is hereby made for a Permit to Construct ( ) or Repair ( ) an Indic idual Sewage Disposal
System at: y_
6o1_, :LC'1 'x+ .91
Lorallon Addscy�{� or Lot No.
lit I,
Address
Address
Type of Building Size Lot Sq. feet
Dwelling—No. of Bedrooms Fxpansion 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
Trench—No. Width Total Length Total leaching area 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,
`Y
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 been issued by the board of health.
Signed
Application Approved By
Application Disapproved for the following reasons
by
Permit No..(. T.7
Issued...s62-e ` F..�.9J(
Date
Date
THE COMMONWEALTH OF MASSACHUSETTS
BOARD OF HEALTH
OF
(firrtifirate of ainmplianre
THIS IS TO CERTIFY, That the Individual Sewage Disposal System constructed ( ) or Repaired ( )
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 dat r'
THE ISSUANCE OF THIS CERTIFICATE SHALL NOT BE CONSTRUED AS A GUARANTEE THAT THE
SYSTEM WILL FUNCTION SATISFACTORY.
DATE
Inspector
by
THE COMMONWEALTH OF MASSACHUSETTS
BOARD OF HEALTH
OF
Tertifiratr of M ntplianre
THIS IS TO CERTIFY, That the Individual Sewage Disposal System constructed ( ) or Repaired
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 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
FEE,! •
Uispnnttl, i9 arks Otonstrnrtian jrrntit
Permission is hereby granted grantedyr
to Construct ( ) or Repair (/ ) an Individual Sewage Disposal ystem
at No tn)-I f ( . '• Street
as shown on the application for Disposal Works Construction Permit No:
DATE
FORM 1255 HOBBS & WARREN. INC.. PUBLISHERS
Board of H