900 Septic Application Permit & Compliance 1970 CHECK OR FILL IN WHERE APPLICABLE
THE COMMONWEALTH OF MASSACHUSETTS
FEE
ffffBOARD O F HEALTH
CC/ OF G/na ?r
Application for Disposal docks Qtunntrnrtintt timid
Application is hereby made for a Permit to Construct ( ) or Repair (Ka'n Indisidual Sewage Disposal
System at:
9;;
ITr No.
o t' Add'ess
_ msrvi.r Addrers
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 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 applicablei tr°:.Orz+<ii
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 f ether agrees not to place the system in
operation until a Certificate of Compliance has been issued by the board of h filth.
Signed. tire � yY
Application Approved By
-...7k
Application Disapproved for the following reasons
THE COMMONWEALTH OF MASSACHUSETTS
BOARD OF HEALTH
errtifiratr of fdnm$►lianre
THIS IS TQ CERTIFY That the Individual Sewage Disposal System constructed ( ) or Repaired
by F -G.u.c -
. a Installer
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 4s-.,E,a. . Inspector_:,.;
No...
THE COMMONWEALTH OF MASSACHUSETTS
BOARD OF HEALTH
OF
Disposal i i.arks Qlnnstrurtinn Permit
•
Permission is hereby granted
to Construct ( ) or Repair (1..er an Individual Sewage Disposal System
at No ^{; L,
Street
as shown on the application for Disposal Works Construction Permit No = ' Dated_...._
DATE
FORM 1255 HOBBS & WARREN. I NC.. PUBLISHERS
• Rwrdol x.plll,
FEE
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