28 Applications & Permits CHECK OR FILL IN WHERE APPLICABLE
No c
THE COMMONWEALTH OF MASSACHUSETTS
BOARD OF HEALTH
(-It it, OFA^'�-.^)nT^.
FEE
Application for 11ispnsul 111 arks Tonotruction jrrmit
Application is hereby made for a Permit to Construct ( ) or Repair (14 an Individual Sewage Disposal
System at: �-- ,ti
its c, f w i
, Lh
VDIL Dwner
Inshllc: Address
Size Lot Sq. feet
Expansion Attic ( ) Garbage Grinder ( )
No. of persons Showers ( ) — Cafeteria ( )
or Lot No.
Arld?c s
Type of Building
Dwelling—No. of Bedrooms
Other—Type of Building
Other fixtures
Design Flow gallons per person per day. Total daily flow gallons.
Septic Tank—1.iquid capacit gallons Length Width Diameter Depth
Disposal Trench—No. Width tr ' Total Length 2 O Total leaching area O O 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
Agreement:
The undersigned agrees to install the aforedescribed Individual Sewage Disposal System
the provisions of Article XI of the State Sanitary Cod The undersig d furth r agrees not to
operation until a Certificate of Compliance has been is ed by thpbgrtrd V„eats
Application Approved By
Sijaedst
.tr tt,. is
Application Disapproved for the following reasons'
in accordance with
place the system in
r, 3Dat
Date
g /
Permit No `X 1 G
Date
5
Issued
Date
THE COMMONWEALTH OF MASSACHUSETTS
i
BOARD OF -HEALTH
Olnttftratr of Qlamplianrr
THIS I T
. . O C1 R f14 h The 4J e�is al System constructed ( ) or Repaired ( )
by , q
at
has been installed in accordance with the provisions of Article XI of The State Sanitary C,pde s described in the
application for Disposal Works Construction Permit No dated CY
THE ISSUANCE OF THIS CERTIFICATE SHALL NOT BE CONSTRUED AS A GUARANTEE THAT THE
SYSTEM WIL,FU�SON SATISFACTORY. J�� fy.
DATE Inspector 6�.�LN
No
OG
THE COMMONWEALTH OF MASSACHUSETTS
BOARS OF r EALTIit-1.
OF
Uts}mnatn>ks
Permission is hereby grantrt
to Construct ( ) or Re¢mt � ) an dividu&l Sewage Disposal System
at No - CJt'�^
nurftrortian Vrrntit
FEE
so-rc` A- C
as shown on the application for Disposal Works Construction Permit No ... Dated
-4( At/ dattIal
Board of nedIBt
DATE
FORM 1255 HOBBS & WARREN. INC.. PUBLISHERS
CHECK OR FILL IN WHERE APPLICABLE
No
THE COMMONWEALTH OF MASSACHUSETTS
BOARD OF HEALTH
OF
FEE---
Appli ration far Elispnsai iflurks Tanntrurtinn lrrmit
Application is hereby made for a Permit to Construct ( ) or Repair (; ) an Individual Sewage Disposal
System at:
Location.Address
Owner
or Lot No.
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 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.
Other Distribution box
Percolation Test Results
Test Pit No. I
Test Pit No. 2
Description of Soil
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
Nature of Repairs or Alterations—Answer when applicable--.,.
.r t , r_...u._.._..Lfq
Agreement:
The undersigned agrees to install the aforedescribed Individual Sewage Disposal System in accordance with
the provisions of 7.3.Thif 5 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
Permit No Issued
Daze
Date
Date
Date
by
at
has been installed in accordance with the provisions of TI TI->
application for Disposal Works Construction Permit No '
THE ISSUANCE OF THIS CERTIFICATE SHALL NOT
SYSTEM WILL FUNCTION SATISFACTORY.
DATF . I L :-t r Inspector - -
THE COMMONWEALTH OF MASSACHUSETTS
BOARD OF HEALTH
'«rrtifiratr of (iCnmplittnrr
THIS, IS TO CERTIFY, That the Individual Sewage Disposal System constructed ( ) or Repaired (PI'
Installer
5 of The State Sanitary Code as described in the
Zr dated ,rats_/ I-k,_J_�
BE CONSTRUED AS A GUARANTEE THAT THE
No
THE COMMONWEALTH OF MASSACHUSETTS
BOARD OF HEALTH
OF
�iopnnat 3 orkn @tnnntrurtinn lrrmit
Permission is hereby granted `
to Construct ( ) or Repair ( ) an Individual Sewage Disposal System
at No '
FEE' -
Street
shown on the application for Disposal Works Construction Permit No
DATE
FORM 1255 HOBBS 8 WARREN. INC.. PUBLISHERS
Dated
Board of Health