1716 Application & Permit 1977 CHECK OR FILL IN WHERE APPLICABLE
No
THE COMMONWEALTH OF MASSACHUSETTS
BOARD OF HEALTH
OF ..,
F
.Applirntinn fur nrkiQtutwtrurtinn rrraii
Application is hereby'made for a Permit to Construct ( ) or Repair ('<an lndir idual Sewage Disposal
System at:
Lrcatiort Address
OwLer
Installer
or Lot No.
Address
Type of Building
Dwelling—No. of Bedrooms Expansion Attic
Other—Type of Building No. of persons
Other fixtures
Design Flow
Septic Tank—Liquid capacity gallons Length Width
Disposal Trench—No. Width Total Length
Seepage Pit No Diameter Depth below inlet
Other Distribution box ( ) Dosing tank ( )
Percolation Test Results Performed by
Test Pit No. 1 minutes per inch
Test Pit No. 2 minutes per inch
Address
Size Lot Sq. feet
Garbage Grinder ( )
Showers ( ) — Cafeteria ( )
gallons per person per day. Total daily flow gallons.
Diameter Depth
Total leaching area sq. ft
Total leaching are'I sq. ft
Date
Depth of Test Pit Depth to ground water
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 aforedescrihed 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 been issued by the board of health.
Signed 1 ' '
Application Approved By
Application Disapproved for the following reasons
T
Date
Dale
Lame2
Permit No
Dat
Date
.J.../........
THE COMMONWEALTH OF MASSACHUSETTS
BOARD OF HEALTH
i-1 CSI
OF ,° Citlt_�a .mac�l
tirrtifiratr of oinntpdaurr
THIS IS TO CERTIFY, That the Individual Sewage Disposal System constructed ( ) or Repaired (v)
by - ( 1 • `)
- -f Installer
i ; .1.-Y.__i +u..14.-.L1
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
Jthpnsttl Marko Qnnstruitinn lrrmit
Permission is hereby granted
to Construct ( .) or Repair (i-Tan Individual Sewage Disposal Stem
at No
Street
as shown on the application for Disposal Works Construction Permit No Dated
DATE
FORM 1255 HOBBS S WARREN. I NC_ PUBLISHERS
Board of Htnith