46 Application & Permit 1980 •
CK OR FILL IN WHERE APPLICABLE
No FEE
THE COMMONWEALTH OF MASSACHUSETTS
BOARD OF HEALTH
OF
Applirutinn far fiinpnsai iliarks Tnnntrurtinn 1rrmit
Application is hereby made for a Permit to Construct ( ) or Repair ( ) an Individual Sewage Disposal
System at:
Location•A ddress or Lot No.
Owner
Address
Install 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 ( ) 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 aforedescrihed Individual Sewage Disposal System in accordance with
the provisions of TITLE 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 hoard of health.
Signed
Date
Application Approved By
Date
Application Disapproved for the following reasons
Date
Permit No . - Issued ,
Date
THE COMMONWEALTH OF MASSACHUSETTS
BOARD OF HEALTH
OF . /(: .. i-rd. QP!1I
t![rrtificntr of tdnnt4+linnre
THIS IS,TO CERTIFY, That the Individual Sewage Disposal System constructed ( ) or Repaired (.�
by - . /,
Installer
at 1; .1 c,.;: - ; .�.- r_
has been installed in accordance with the provisions of TI LC, 5 of The State Sanitary Code as described in the
application for Disposal Works Construction Permit No At
THE ISSUANCE OF THIS CERTIFICATE SHALL NOT BE CONSTRUED AS A GUARANTEE THAT THE
SYSTEM WILL FUNCTION SATISFACTORY.
DATE Inspector
No
THE COMMONWEALTH OF MASSACHUSETTS
BOARD OF HEALTH
OF
flin.pnnttl Marko fdnnntrurtian 1rrmit
Permission is hereby granted. -
to Construct ( ) or Repair ('' ) an Individual Sewage Disposal System
at No
FEE
s,r
as shown on the application for Disposal Works Construction Permit No Dated
Board of Health
DATE
FORM 1255 Noses a WARREN, INC . PUBLISHERS